Healthcare Provider Details

I. General information

NPI: 1326063272
Provider Name (Legal Business Name): TIFFENEY SU MAHAFFEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3394 CERTIER RD
SARDINIA OH
45171-9432
US

IV. Provider business mailing address

3394 CERTIER RD
SARDINIA OH
45171-9432
US

V. Phone/Fax

Practice location:
  • Phone: 937-288-2408
  • Fax:
Mailing address:
  • Phone: 937-288-2408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number400465800305
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: