MEDICARE: TIFFANY MCKENNON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	376K00000X	Nurse's Aide
2	251E00000X	Home Health Agency
3	253Z00000X	In Home Supportive Care Agency
4	291U00000X	Clinical Medical Laboratory	10D2254281	FL
5	376J00000X	Homemaker
6	374U00000X	Home Health Aide		FL

General Provider Information

NPI Number	:	1720509755
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY MCKENNON

Provider Business Mailing Address
First Line	:	11039 COLONIAL TAVERN LN
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32221-2123
Country	:	US
Telephone Number	:	904-450-1430
Fax Number	:

Provider Business Practice Location Address
First Line	:	11039 COLONIAL TAVERN LN
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32221-2123
Country	:	US
Telephone Number	:	904-450-1430
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/29/2017
Last Update Date	:	03/28/2022

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