Provider Demographics
NPI:1780092940
Name:JOHNSON, TIFFANY
Entity type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:
Last Name:JOHNSON
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 1:217693 COUNTY ROAD 20N
Mailing Address - Street 2:
Mailing Address - City:WEST UNITY
Mailing Address - State:OH
Mailing Address - Zip Code:43570-9726
Mailing Address - Country:US
Mailing Address - Phone:419-630-6480
Mailing Address - Fax:
Practice Address - Street 1:21763 COUNTY ROAD 20N
Practice Address - Street 2:
Practice Address - City:WEST UNITY
Practice Address - State:OH
Practice Address - Zip Code:43570-9726
Practice Address - Country:US
Practice Address - Phone:419-630-6480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-31
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH401473551212374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0094760Medicaid
OH8601016OtherDODD CONTRACT NUMBER