Provider Demographics
NPI:1205582509
Name:WALLACE, TIFFANY (QMHP)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:WALLACE
Suffix:
Gender:F
Credentials:QMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5881 LUDINGTON DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-1546
Mailing Address - Country:US
Mailing Address - Phone:757-288-1363
Mailing Address - Fax:
Practice Address - Street 1:5881 LUDINGTON DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-1546
Practice Address - Country:US
Practice Address - Phone:757-288-1363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-24
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6728Medicaid