Provider Demographics
NPI:1104683911
Name:MOORE, TIFFANY NICOLE
Entity type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:NICOLE
Last Name:MOORE
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 1:7432 WASHINGTON ST APT 402
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60130-1533
Mailing Address - Country:US
Mailing Address - Phone:708-805-3721
Mailing Address - Fax:
Practice Address - Street 1:219 W CHICAGO AVE STE 200
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60654-5600
Practice Address - Country:US
Practice Address - Phone:832-761-3176
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-28
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator