Provider Demographics
NPI:1720509755
Name:MCKENNON, TIFFANY
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:MCKENNON
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 1:11039 COLONIAL TAVERN LN
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32221-2123
Mailing Address - Country:US
Mailing Address - Phone:904-450-1430
Mailing Address - Fax:
Practice Address - Street 1:11039 COLONIAL TAVERN LN
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32221-2123
Practice Address - Country:US
Practice Address - Phone:904-450-1430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-29
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
376K00000X, 251E00000X, 253Z00000X, 376J00000X
FL10D2254281291U00000X
FL374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No376K00000XNursing Service Related ProvidersNurse's Aide
No251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
No291U00000XLaboratoriesClinical Medical Laboratory
No376J00000XNursing Service Related ProvidersHomemaker