Provider Demographics
NPI:1639546856
Name:RICKETT, TIFFANY ELAINE (RN BSN)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ELAINE
Last Name:RICKETT
Suffix:
Gender:F
Credentials:RN BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1195 N WILDWOOD ST
Mailing Address - Street 2:
Mailing Address - City:WESTLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48185-3503
Mailing Address - Country:US
Mailing Address - Phone:734-620-8873
Mailing Address - Fax:
Practice Address - Street 1:2766 W 11 MILE RD
Practice Address - Street 2:
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-3033
Practice Address - Country:US
Practice Address - Phone:248-542-2424
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-24
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704276787163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse