Healthcare Provider Details

I. General information

NPI: 1578355236
Provider Name (Legal Business Name): TIFUH TAKEH BRONHILDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2025
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date: 03/23/2026
Reactivation Date: 08/06/2026

III. Provider practice location address

1270 PRINCE AVE SUITE 102
ATHENS GA
30606
US

IV. Provider business mailing address

1270 PRINCE AVE SUITE 102
ATHENS GA
30606
US

V. Phone/Fax

Practice location:
  • Phone: 706-475-7055
  • Fax:
Mailing address:
  • Phone: 706-475-7055
  • 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: