Healthcare Provider Details

I. General information

NPI: 1174455919
Provider Name (Legal Business Name): TIFFANY RAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16150 CICERO AVE STE 12
OAK FOREST IL
60452-4136
US

IV. Provider business mailing address

16150 CICERO AVE STE 12
OAK FOREST IL
60452-4136
US

V. Phone/Fax

Practice location:
  • Phone: 708-580-0119
  • Fax:
Mailing address:
  • Phone: 708-580-0119
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number043111861
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: