Provider Demographics
NPI:1215509781
Name:ROBERTS, TIFFANY MONIQUE
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MONIQUE
Last Name:ROBERTS
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 1:6521 LARCOMB DR
Mailing Address - Street 2:
Mailing Address - City:HUBER HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:45424-3036
Mailing Address - Country:US
Mailing Address - Phone:937-510-1231
Mailing Address - Fax:
Practice Address - Street 1:6521 LARCOMB DR
Practice Address - Street 2:
Practice Address - City:HUBER HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:45424-3036
Practice Address - Country:US
Practice Address - Phone:937-510-1231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-14
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X
OH0304907251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0304907Medicaid