Healthcare Provider Details

I. General information

NPI: 1093584039
Provider Name (Legal Business Name): TIFFANY DAUGHERTY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/01/2024
Last Update Date: 01/01/2024
Certification Date: 12/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3026 LAKE CITY HWY
ROCKY TOP TN
37769-5533
US

IV. Provider business mailing address

3026 LAKE CITY HWY
ROCKY TOP TN
37769-5533
US

V. Phone/Fax

Practice location:
  • Phone: 865-246-8941
  • Fax:
Mailing address:
  • Phone: 865-246-8941
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number245722
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: