Provider Demographics
NPI:1801347448
Name:KIMBROUGH, TIFFANY (COTA)
Entity type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:
Last Name:KIMBROUGH
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33909 E JENKINS RD
Mailing Address - Street 2:
Mailing Address - City:LONE JACK
Mailing Address - State:MO
Mailing Address - Zip Code:64070-9155
Mailing Address - Country:US
Mailing Address - Phone:816-616-9566
Mailing Address - Fax:
Practice Address - Street 1:3980 SOUTH JACKSON DRIVE
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64057
Practice Address - Country:US
Practice Address - Phone:816-478-5605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011015347172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker