Provider Demographics
NPI:1821685165
Name:JOHNSON, TIFFANY R
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:R
Last Name:JOHNSON
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 1:117 GILMER ST
Mailing Address - Street 2:
Mailing Address - City:BLUEFIELD
Mailing Address - State:WV
Mailing Address - Zip Code:24701-4101
Mailing Address - Country:US
Mailing Address - Phone:804-833-8502
Mailing Address - Fax:
Practice Address - Street 1:117 GILMER ST
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701-4101
Practice Address - Country:US
Practice Address - Phone:804-833-8502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant