=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427631639
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIFFANY CLEGG
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2021
-----------------------------------------------------
Last Update Date | 05/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3620 MCDONALD RD
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37914-6215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-964-8132
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3620 MCDONALD RD
-----------------------------------------------------
City | KNOXVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37914-6215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 865-964-8132
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number | 1000000028464
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------