Provider Demographics
NPI:1104248749
Name:TATE, TIFFANY
Entity type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:
Last Name:TATE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 W 135TH ST
Mailing Address - Street 2:APT 10K
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10037-2602
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 W 135TH ST
Practice Address - Street 2:APT 10 K
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10037-2602
Practice Address - Country:US
Practice Address - Phone:917-846-7582
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-16
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY941385515174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist