Provider Demographics
NPI:1255160255
Name:PAGE COOPER, TIFFANY
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:PAGE COOPER
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 1:2208 KOKO LN
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21216-2926
Mailing Address - Country:US
Mailing Address - Phone:301-800-1478
Mailing Address - Fax:
Practice Address - Street 1:5011 ARBUTUS AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5723
Practice Address - Country:US
Practice Address - Phone:443-759-8921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
MD01706-24-A172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No251B00000XAgenciesCase Management