Provider Demographics
NPI:1689212896
Name:DRUMMER, TIFFANIE ETTICE
Entity Type:Individual
Prefix:
First Name:TIFFANIE
Middle Name:ETTICE
Last Name:DRUMMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2076 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-5829
Mailing Address - Country:US
Mailing Address - Phone:510-408-8613
Mailing Address - Fax:
Practice Address - Street 1:2076 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-5829
Practice Address - Country:US
Practice Address - Phone:510-757-8396
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-18
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55647225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty