Provider Demographics
NPI:1104626423
Name:RICHARD, TIFFANIE R
Entity type:Individual
Prefix:
First Name:TIFFANIE
Middle Name:R
Last Name:RICHARD
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1141 CATFISH LN
Mailing Address - Street 2:
Mailing Address - City:BASTROP
Mailing Address - State:TX
Mailing Address - Zip Code:78602-2328
Mailing Address - Country:US
Mailing Address - Phone:531-777-8987
Mailing Address - Fax:531-888-8655
Practice Address - Street 1:1141 CATFISH LN
Practice Address - Street 2:
Practice Address - City:BASTROP
Practice Address - State:TX
Practice Address - Zip Code:78602-2328
Practice Address - Country:US
Practice Address - Phone:531-777-8987
Practice Address - Fax:531-888-8655
Is Sole Proprietor?:No
Enumeration Date:2025-03-17
Last Update Date:2025-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE38017092372500000X, 372600000X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion