Provider Demographics
NPI:1659145043
Name:WALLACE, TIFFANY (CNA, CMA, MS)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:CNA, CMA, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:909 S 76TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68114-4519
Mailing Address - Country:US
Mailing Address - Phone:400-239-0210
Mailing Address - Fax:
Practice Address - Street 1:909 S 76TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68114-4519
Practice Address - Country:US
Practice Address - Phone:400-239-0210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-07
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NA376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide