Provider Demographics
NPI:1255150033
Name:CLARK, TIFFANIE SHEREA (RMA)
Entity type:Individual
Prefix:MISS
First Name:TIFFANIE
Middle Name:SHEREA
Last Name:CLARK
Suffix:
Gender:F
Credentials:RMA
Other - Prefix:
Other - First Name:TIFFANIE
Other - Middle Name:
Other - Last Name:THOMAS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5130 ROSE HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:HOLLY
Mailing Address - State:MI
Mailing Address - Zip Code:48442-9507
Mailing Address - Country:US
Mailing Address - Phone:248-531-2407
Mailing Address - Fax:248-531-2407
Practice Address - Street 1:5130 ROSE HILL BLVD
Practice Address - Street 2:
Practice Address - City:HOLLY
Practice Address - State:MI
Practice Address - Zip Code:48442-9507
Practice Address - Country:US
Practice Address - Phone:248-531-2407
Practice Address - Fax:248-531-2407
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-08
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI277536403104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness