Provider Demographics
NPI:1932687753
Name:GREEN, TIFFANY D
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:D
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 1:717 WOODLAND AVE
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:FL
Mailing Address - Zip Code:32351-1312
Mailing Address - Country:US
Mailing Address - Phone:850-354-3530
Mailing Address - Fax:
Practice Address - Street 1:717 WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:FL
Practice Address - Zip Code:32351-1312
Practice Address - Country:US
Practice Address - Phone:850-354-3530
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-02
Last Update Date:2018-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172V00000X, 253Z00000X
FLPN5163698164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No172V00000XOther Service ProvidersCommunity Health Worker
No253Z00000XAgenciesIn Home Supportive Care