Provider Demographics
NPI:1881197424
Name:SO, TIFFANY ANN (CM)
Entity type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:ANN
Last Name:SO
Suffix:
Gender:F
Credentials:CM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1522 S 1100 E
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84105-2425
Mailing Address - Country:US
Mailing Address - Phone:801-467-1200
Mailing Address - Fax:801-467-1210
Practice Address - Street 1:1522 S 1100 E
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84105-2425
Practice Address - Country:US
Practice Address - Phone:801-467-1200
Practice Address - Fax:801-467-1210
Is Sole Proprietor?:No
Enumeration Date:2018-03-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator