Provider Demographics
NPI:1104331792
Name:HARRIS, TIFFANY
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:HARRIS
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:PO BOX 1771
Mailing Address - Street 2:
Mailing Address - City:SEFFNER
Mailing Address - State:FL
Mailing Address - Zip Code:33583-1771
Mailing Address - Country:US
Mailing Address - Phone:813-473-9510
Mailing Address - Fax:813-435-3246
Practice Address - Street 1:612 CALHOUN AVE
Practice Address - Street 2:
Practice Address - City:SEFFNER
Practice Address - State:FL
Practice Address - Zip Code:33584-3617
Practice Address - Country:US
Practice Address - Phone:813-473-9510
Practice Address - Fax:813-435-3246
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-05
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
374U00000X, 376J00000X, 376K00000X, 385H00000X
FL23494372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372600000XNursing Service Related ProvidersAdult Companion
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
No376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty
No376K00000XNursing Service Related ProvidersNurse's AideGroup - Single Specialty
No385H00000XRespite Care FacilityRespite CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL47-5660279Medicaid