Provider Demographics
NPI:1205532447
Name:HERNANDEZ, TIFFANY HART (COTA)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:HART
Last Name:HERNANDEZ
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9226 W STIRRUP DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-5799
Mailing Address - Country:US
Mailing Address - Phone:208-891-6205
Mailing Address - Fax:
Practice Address - Street 1:3086 W MILANO DR
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-7288
Practice Address - Country:US
Practice Address - Phone:208-996-0552
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-31
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID2680224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant