Healthcare Provider Details

I. General information

NPI: 1588496129
Provider Name (Legal Business Name): TIFFANY K SMITH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2024
Last Update Date: 08/14/2024
Certification Date: 08/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

KADENA DISEASE MANAGEMENT 18TH MDG UNIT 5267 KADENA AB, JAPAN
APO AP
96368
US

IV. Provider business mailing address

KADENA DISEASE MANAGEMENT 18TH MDG UNIT 5267 KADENA AB, JAPAN
APO AP
96368
US

V. Phone/Fax

Practice location:
  • Phone: 409-553-1015
  • Fax:
Mailing address:
  • Phone: 409-553-1015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number72558
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: