Healthcare Provider Details

I. General information

NPI: 1326759846
Provider Name (Legal Business Name): TIFFANY MARIE CARRANCO CCM, CPSS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2022
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

344 E 100 S STE 301
SALT LAKE CITY UT
84111-1727
US

IV. Provider business mailing address

344 E 100 S STE 301
SALT LAKE CITY UT
84111-1727
US

V. Phone/Fax

Practice location:
  • Phone: 801-428-4257
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberF25-123810
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberF25-120397
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: