Healthcare Provider Details

I. General information

NPI: 1558556662
Provider Name (Legal Business Name): TIFFANY DAVIS HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 03/04/2021
Certification Date: 03/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5220 S LINDBERGH BLVD
SAINT LOUIS MO
63126-3519
US

IV. Provider business mailing address

3473 RIDER TRL S
EARTH CITY MO
63045-1110
US

V. Phone/Fax

Practice location:
  • Phone: 314-843-7233
  • Fax:
Mailing address:
  • Phone: 314-328-0088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHA038732
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: