Provider Demographics
NPI:1952079428
Name:OLLIVER, TIFFANY (PTA)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:OLLIVER
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6045 SUNSHINE DR
Mailing Address - Street 2:
Mailing Address - City:FERNDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98248-9234
Mailing Address - Country:US
Mailing Address - Phone:941-468-8860
Mailing Address - Fax:
Practice Address - Street 1:456 C ST
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:WA
Practice Address - Zip Code:98230-4238
Practice Address - Country:US
Practice Address - Phone:360-332-8733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-31
Last Update Date:2021-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160807192225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant