MEDICARE: TIFFANY D GREEN

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	172V00000X	Community Health Worker
2	253Z00000X	In Home Supportive Care Agency
3	164W00000X	Licensed Practical Nurse	PN5163698	FL

General Provider Information

NPI Number	:	1932687753
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY D GREEN

Provider Business Mailing Address
First Line	:	717 WOODLAND AVE
Second Line	:
City	:	QUINCY
State	:	FL
Zip	:	32351-1312
Country	:	US
Telephone Number	:	850-354-3530
Fax Number	:

Provider Business Practice Location Address
First Line	:	717 WOODLAND AVE
Second Line	:
City	:	QUINCY
State	:	FL
Zip	:	32351-1312
Country	:	US
Telephone Number	:	850-354-3530
Fax Number	:

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

Provider Enumeration Date	:	08/02/2018
Last Update Date	:	08/02/2018

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Directions to “ TIFFANY D GREEN ” Practice Location

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