Healthcare Provider Details

I. General information

NPI: 1467804054
Provider Name (Legal Business Name): TIFFANY ALENA WATSON CNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2016
Last Update Date: 07/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

709 E CHURCH LN
PHILADELPHIA PA
19144-1436
US

IV. Provider business mailing address

709 E CHURCH LN APT G1
PHILADELPHIA PA
19144-1443
US

V. Phone/Fax

Practice location:
  • Phone: 267-423-2426
  • Fax:
Mailing address:
  • Phone: 267-437-0264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number10001903
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: