Healthcare Provider Details

I. General information

NPI: 1417456617
Provider Name (Legal Business Name): TIFFANY DRAKE RN, CCM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/03/2018
Last Update Date: 06/08/2021
Certification Date: 06/08/2021
Deactivation Date: 04/26/2021
Reactivation Date: 06/08/2021

III. Provider practice location address

644 PEARCE DR
POTTSBORO TX
75076-6988
US

IV. Provider business mailing address

PO BOX 2107
POTTSBORO TX
75076-6988
US

V. Phone/Fax

Practice location:
  • Phone: 903-624-4529
  • Fax: 903-582-7281
Mailing address:
  • Phone: 903-624-4529
  • Fax: 903-582-7281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number652003
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: