Provider Demographics
NPI:1629519681
Name:TAPP, TIFFANY (LICENSED PEDORTHIST)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:TAPP
Suffix:
Gender:F
Credentials:LICENSED PEDORTHIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4965 STATE ROUTE 56 W
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:KY
Mailing Address - Zip Code:42409-9552
Mailing Address - Country:US
Mailing Address - Phone:270-639-7954
Mailing Address - Fax:
Practice Address - Street 1:426 N ELM ST
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-2932
Practice Address - Country:US
Practice Address - Phone:270-869-9197
Practice Address - Fax:270-844-8045
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-10
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYCFM03052224900000X
KY111358224L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224L00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPedorthist
No224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy Fitter