Provider Demographics
NPI:1700631744
Name:BURNHAM, TIFFANY P
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:P
Last Name:BURNHAM
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 1:7310 SANDALWOOD DR APT 303
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-3740
Mailing Address - Country:US
Mailing Address - Phone:312-522-2099
Mailing Address - Fax:
Practice Address - Street 1:7310 SANDALWOOD DR APT 303
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-3740
Practice Address - Country:US
Practice Address - Phone:312-522-2099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-23
Last Update Date:2024-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
172A00000X, 172V00000X, 251G00000X, 253Z00000X, 332U00000X, 347C00000X, 171M00000X
IL3002560208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No172A00000XOther Service ProvidersDriver
No172V00000XOther Service ProvidersCommunity Health Worker
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No251G00000XAgenciesHospice Care, Community Based
No253Z00000XAgenciesIn Home Supportive Care
No332U00000XSuppliersHome Delivered Meals
No347C00000XTransportation ServicesPrivate Vehicle