MEDICARE: TIFFANY FOUNTAIN LVN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164X00000X	Licensed Vocational Nurse	756820	CA

General Provider Information

NPI Number	:	1003761982
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY FOUNTAIN LVN

Provider Business Mailing Address
First Line	:	268 LEWELLING BLVD
Second Line	:
City	:	ASHLAND
State	:	CA
Zip	:	94580-1632
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5432 LAWTON AVE
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94618-1110
Country	:	US
Telephone Number	:	510-640-3914
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/04/2026
Last Update Date	:	03/04/2026

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