Healthcare Provider Details

I. General information

NPI: 1659145043
Provider Name (Legal Business Name): TIFFANY WALLACE CNA, CMA, MS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2023
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 S 76TH ST
OMAHA NE
68114-4519
US

IV. Provider business mailing address

909 S 76TH ST
OMAHA NE
68114-4519
US

V. Phone/Fax

Practice location:
  • Phone: 400-239-0210
  • Fax:
Mailing address:
  • Phone: 400-239-0210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberNA
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: