Provider Demographics
NPI:1174156574
Name:ELAM, TIFFANY SHAKEEMA
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:SHAKEEMA
Last Name:ELAM
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 1:10519 PENELOPE PL UNIT 104
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34654-1744
Mailing Address - Country:US
Mailing Address - Phone:850-276-1836
Mailing Address - Fax:
Practice Address - Street 1:7045 EVERGREEN WOODS TRL
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:FL
Practice Address - Zip Code:34608-1306
Practice Address - Country:US
Practice Address - Phone:352-596-8371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-14
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA14674224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant