Provider Demographics
NPI:1790359032
Name:DONNELLY, TIFFANY SHERICE
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:SHERICE
Last Name:DONNELLY
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 1:1816 SE ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:TOPEKA
Mailing Address - State:KS
Mailing Address - Zip Code:66607-1221
Mailing Address - Country:US
Mailing Address - Phone:785-596-7083
Mailing Address - Fax:
Practice Address - Street 1:1816 SE ADAMS ST
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66607-1221
Practice Address - Country:US
Practice Address - Phone:785-596-7083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-19
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO1736303374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO040807Medicaid