Provider Demographics
NPI:1649832080
Name:JOHNSON, TIFFANY LYNNJOY
Entity type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:LYNNJOY
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:ANGEL
Other - Middle Name:DENISE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:519 QUICKSILVER TRL
Mailing Address - Street 2:
Mailing Address - City:FORT MILL
Mailing Address - State:SC
Mailing Address - Zip Code:29708-6507
Mailing Address - Country:US
Mailing Address - Phone:803-981-4750
Mailing Address - Fax:866-415-8349
Practice Address - Street 1:519 QUICKSILVER TRL
Practice Address - Street 2:
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29708-6507
Practice Address - Country:US
Practice Address - Phone:803-981-4750
Practice Address - Fax:866-415-8349
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-06
Last Update Date:2019-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCIHCP-0913374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty