Provider Demographics
NPI:1790064111
Name:HENRY, TIFFANIE M
Entity Type:Individual
Prefix:
First Name:TIFFANIE
Middle Name:M
Last Name:HENRY
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 1:55417 MAPLE HTS APT REAR
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:OH
Mailing Address - Zip Code:43912-1524
Mailing Address - Country:US
Mailing Address - Phone:740-484-9282
Mailing Address - Fax:
Practice Address - Street 1:55417 MAPLE HTS APT REAR
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:OH
Practice Address - Zip Code:43912-1524
Practice Address - Country:US
Practice Address - Phone:740-484-9282
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-16
Last Update Date:2023-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0050393Medicaid
OH2860793Medicaid