Provider Demographics
NPI:1023784717
Name:FANUCCHI, TIFFANI ANNE (LE)
Entity type:Individual
Prefix:
First Name:TIFFANI
Middle Name:ANNE
Last Name:FANUCCHI
Suffix:
Gender:F
Credentials:LE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 MILL ST STE F
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-4771
Mailing Address - Country:US
Mailing Address - Phone:530-913-6887
Mailing Address - Fax:
Practice Address - Street 1:152 MILL ST STE F
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-4771
Practice Address - Country:US
Practice Address - Phone:530-913-6887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-21
Last Update Date:2021-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8339246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant