Provider Demographics
NPI:1922822105
Name:BOGGS, TIFFANY FAWN
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:FAWN
Last Name:BOGGS
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 316
Mailing Address - Street 2:
Mailing Address - City:LUCERNE
Mailing Address - State:CA
Mailing Address - Zip Code:95458-0316
Mailing Address - Country:US
Mailing Address - Phone:707-998-1800
Mailing Address - Fax:
Practice Address - Street 1:14715 E. HWY 20
Practice Address - Street 2:14725 CATHOLIC CHURCH RD.
Practice Address - City:CLEARLAKE OAKS
Practice Address - State:CA
Practice Address - Zip Code:95423-9542
Practice Address - Country:US
Practice Address - Phone:707-998-1800
Practice Address - Fax:707-998-0122
Is Sole Proprietor?:No
Enumeration Date:2024-11-13
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist