Provider Demographics
NPI:1922648179
Name:MCCOLLUM, TIFFANY SCOTT (PRSS)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:SCOTT
Last Name:MCCOLLUM
Suffix:
Gender:F
Credentials:PRSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1126 NW 10TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73106-7032
Mailing Address - Country:US
Mailing Address - Phone:405-679-6525
Mailing Address - Fax:
Practice Address - Street 1:8515 NE 25TH ST
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:OK
Practice Address - Zip Code:73084-3818
Practice Address - Country:US
Practice Address - Phone:405-796-7010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist