Provider Demographics
NPI:1912573510
Name:GREEN, TIFFANY DANIELLE
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:DANIELLE
Last Name:GREEN
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 1:914 TIMBERWOOD CROSSING CT
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-7518
Mailing Address - Country:US
Mailing Address - Phone:314-393-1639
Mailing Address - Fax:
Practice Address - Street 1:6207 N LINDBERGH BLVD
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-2817
Practice Address - Country:US
Practice Address - Phone:314-393-1639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator