Provider Demographics
NPI:1295292985
Name:CHURCHWELL, TIFFANY DENISE (CNA)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:DENISE
Last Name:CHURCHWELL
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 BROAD ST STE 3148
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30901-1467
Mailing Address - Country:US
Mailing Address - Phone:762-383-8350
Mailing Address - Fax:
Practice Address - Street 1:601 BROAD ST STE 3148
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-1467
Practice Address - Country:US
Practice Address - Phone:762-383-8350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-28
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0000037316376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide