MEDICARE: TIFFANY SMITH

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	172A00000X	Driver

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	00000000000	OTHER		NONE

General Provider Information

NPI Number	:	1174108583
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY SMITH

Provider Business Mailing Address
First Line	:	5258 N 84TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53225-3502
Country	:	US
Telephone Number	:	414-514-2919
Fax Number	:

Provider Business Practice Location Address
First Line	:	5258 N 84TH ST
Second Line	:
City	:	MILWAUKEE
State	:	WI
Zip	:	53225-3502
Country	:	US
Telephone Number	:	414-514-2919
Fax Number	:

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

Provider Enumeration Date	:	03/17/2021
Last Update Date	:	03/17/2021

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Directions to “ TIFFANY SMITH ” Practice Location

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