Provider Demographics
NPI:1851138317
Name:CHERRY, TIFFANY
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:CHERRY
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 1666
Mailing Address - Street 2:
Mailing Address - City:WALL
Mailing Address - State:NJ
Mailing Address - Zip Code:07719-1666
Mailing Address - Country:US
Mailing Address - Phone:901-620-8105
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 1666
Practice Address - Street 2:
Practice Address - City:WALL
Practice Address - State:NJ
Practice Address - Zip Code:07719-1666
Practice Address - Country:US
Practice Address - Phone:901-620-8105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-11
Last Update Date:2024-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ172A00000X, 171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172A00000XOther Service ProvidersDriverGroup - Multi-Specialty