Provider Demographics
NPI:1982001087
Name:ELLIS, TIFFANY
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:ELLIS
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 1:140 SANDALWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FELTON
Mailing Address - State:DE
Mailing Address - Zip Code:19943-2937
Mailing Address - Country:US
Mailing Address - Phone:302-424-0600
Mailing Address - Fax:302-422-6214
Practice Address - Street 1:140 SANDALWOOD DR
Practice Address - Street 2:
Practice Address - City:FELTON
Practice Address - State:DE
Practice Address - Zip Code:19943-2937
Practice Address - Country:US
Practice Address - Phone:302-424-0600
Practice Address - Fax:302-422-6214
Is Sole Proprietor?:No
Enumeration Date:2014-12-04
Last Update Date:2014-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEP3W3P4J8374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician