Provider Demographics
NPI:1912544727
Name:JOHNSON, TIFFANY L
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:L
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 1:10412 W CUSTER AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53225-3218
Mailing Address - Country:US
Mailing Address - Phone:414-213-7073
Mailing Address - Fax:
Practice Address - Street 1:10412 W CUSTER AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53225-3218
Practice Address - Country:US
Practice Address - Phone:414-213-7073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-30
Last Update Date:2020-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI843815038Medicaid