Healthcare Provider Details

I. General information

NPI: 1477158111
Provider Name (Legal Business Name): TIFFANY JANG SOCHUREK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2020
Last Update Date: 12/01/2020
Certification Date: 10/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 ASHLEY AVE
CHARLESTON SC
29425-0100
US

IV. Provider business mailing address

99 WESTEDGE ST APT 508
CHARLESTON SC
29403-4993
US

V. Phone/Fax

Practice location:
  • Phone: 843-792-1414
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number1160398
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: