Healthcare Provider Details

I. General information

NPI: 1790357143
Provider Name (Legal Business Name): TIFFANY KATINA HALEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2021
Last Update Date: 08/31/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2051 FERGUSON MILL RD
SILVER CREEK MS
39663-4435
US

IV. Provider business mailing address

2051 FERGUSON MILL RD
SILVER CREEK MS
39663-4435
US

V. Phone/Fax

Practice location:
  • Phone: 601-754-3978
  • Fax: 351-205-1434
Mailing address:
  • Phone: 601-754-3978
  • Fax: 351-205-1434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: