Provider Demographics
NPI:1790268126
Name:FORTT, TIFFANI
Entity Type:Individual
Prefix:
First Name:TIFFANI
Middle Name:
Last Name:FORTT
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 1:3702 COMANCHE AVE
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-4305
Mailing Address - Country:US
Mailing Address - Phone:810-391-1632
Mailing Address - Fax:
Practice Address - Street 1:2284 S BALLENGER HWY STE G
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-3446
Practice Address - Country:US
Practice Address - Phone:810-391-1632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-11
Last Update Date:2018-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other