Provider Demographics
NPI:1386026177
Name:SULLIVAN, TIFFANY (LMT)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6490 S MCCARRAN BLVD
Mailing Address - Street 2:F52
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89509-6165
Mailing Address - Country:US
Mailing Address - Phone:775-400-8876
Mailing Address - Fax:
Practice Address - Street 1:6490 S MCCARRAN BLVD
Practice Address - Street 2:F52
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89509-6165
Practice Address - Country:US
Practice Address - Phone:775-400-8876
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-29
Last Update Date:2015-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNVMT.7343174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist