Healthcare Provider Details

I. General information

NPI: 1699098285
Provider Name (Legal Business Name): MRS. TIFFANY N. FRALEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TIFFANY N. WILBURN

II. Dates (important events)

Enumeration Date: 03/10/2010
Last Update Date: 01/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

57407 TWENTYNINE PALMS HIGHWAY SUITE F
YUCCA VALLEY CA
92284
US

IV. Provider business mailing address

57407 TWENTYNINE PALMS HIGHWAY SUITE F
YUCCA VALLEY CA
92284
US

V. Phone/Fax

Practice location:
  • Phone: 760-366-1541
  • Fax: 760-228-1614
Mailing address:
  • Phone: 760-366-1541
  • Fax: 760-228-1614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
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: