Provider Demographics
NPI:1740069830
Name:BREVALDO, TIFANY (LPN)
Entity type:Individual
Prefix:
First Name:TIFANY
Middle Name:
Last Name:BREVALDO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:TIFANY
Other - Middle Name:
Other - Last Name:VANTERPOOL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:1812 S L ST
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-3962
Mailing Address - Country:US
Mailing Address - Phone:904-814-3499
Mailing Address - Fax:
Practice Address - Street 1:4014 S 270TH ST
Practice Address - Street 2:
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-7139
Practice Address - Country:US
Practice Address - Phone:253-945-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-27
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5252259164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse