Provider Demographics
NPI:1205156692
Name:WHITE, TIFFANI SHEVERE
Entity type:Individual
Prefix:
First Name:TIFFANI
Middle Name:SHEVERE
Last Name:WHITE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TIFFANI
Other - Middle Name:SHEVERE
Other - Last Name:DALEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:42 MARIO DR
Mailing Address - Street 2:
Mailing Address - City:TROTWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45426-2915
Mailing Address - Country:US
Mailing Address - Phone:937-679-6628
Mailing Address - Fax:
Practice Address - Street 1:42 MARIO DR
Practice Address - Street 2:
Practice Address - City:TROTWOOD
Practice Address - State:OH
Practice Address - Zip Code:45426-2915
Practice Address - Country:US
Practice Address - Phone:937-679-6628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-08
Last Update Date:2010-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN. 139913164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse