Provider Demographics
NPI:1740466713
Name:LLAMAS, TIFFANY
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:LLAMAS
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 1:133 ASH ST
Mailing Address - Street 2:
Mailing Address - City:MORENCI
Mailing Address - State:AZ
Mailing Address - Zip Code:85540-9640
Mailing Address - Country:US
Mailing Address - Phone:928-865-4844
Mailing Address - Fax:
Practice Address - Street 1:133 ASH ST
Practice Address - Street 2:
Practice Address - City:MORENCI
Practice Address - State:AZ
Practice Address - Zip Code:85540-9640
Practice Address - Country:US
Practice Address - Phone:928-865-4844
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-21
Last Update Date:2008-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ284114Medicaid