Provider Demographics
NPI:1891239364
Name:FENNELL, TIFFANY S (LMT)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:S
Last Name:FENNELL
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 FOREST AVE
Mailing Address - Street 2:APT 8-C
Mailing Address - City:AMBLER
Mailing Address - State:PA
Mailing Address - Zip Code:19002-5934
Mailing Address - Country:US
Mailing Address - Phone:215-740-4213
Mailing Address - Fax:
Practice Address - Street 1:125 FOREST AVE
Practice Address - Street 2:APT 8-C
Practice Address - City:AMBLER
Practice Address - State:PA
Practice Address - Zip Code:19002-5934
Practice Address - Country:US
Practice Address - Phone:215-740-4213
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-18
Last Update Date:2016-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG005039174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist