Healthcare Provider Details

I. General information

NPI: 1780092940
Provider Name (Legal Business Name): MRS. TIFFANY JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2014
Last Update Date: 07/31/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21763 COUNTY ROAD 20N
WEST UNITY OH
43570-9726
US

IV. Provider business mailing address

217693 COUNTY ROAD 20N
WEST UNITY OH
43570-9726
US

V. Phone/Fax

Practice location:
  • Phone: 419-630-6480
  • Fax:
Mailing address:
  • Phone: 419-630-6480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number401473551212
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: