Healthcare Provider Details

I. General information

NPI: 1134868458
Provider Name (Legal Business Name): TIFFANY JENNIFER BAUMBACH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TIFFANY JENNIFER BAUMBACH

II. Dates (important events)

Enumeration Date: 06/03/2022
Last Update Date: 06/03/2022
Certification Date: 06/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14600 SHERMAN WAY STE 100D
VAN NUYS CA
91405-5869
US

IV. Provider business mailing address

18424 BERMUDA ST
PORTER RANCH CA
91326-3102
US

V. Phone/Fax

Practice location:
  • Phone: 818-374-6901
  • Fax:
Mailing address:
  • Phone: 818-929-5332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: