Provider Demographics
NPI:1992008791
Name:WALLS, TIFFANY R
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:R
Last Name:WALLS
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 1:5501 DELMAR BLVD STE B300
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63112-3078
Mailing Address - Country:US
Mailing Address - Phone:314-897-0289
Mailing Address - Fax:
Practice Address - Street 1:5501 DELMAR BLVD STE B300
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63112-3078
Practice Address - Country:US
Practice Address - Phone:314-897-0289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-16
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator