Provider Demographics
NPI:1003708033
Name:BLACKHAM, TIFFANY (HBCE, CD)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:BLACKHAM
Suffix:
Gender:F
Credentials:HBCE, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5751 S PEARL ST
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89120-2509
Mailing Address - Country:US
Mailing Address - Phone:702-205-6073
Mailing Address - Fax:
Practice Address - Street 1:1525 MESA VERDE DR E STE 210
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-5219
Practice Address - Country:US
Practice Address - Phone:702-205-6073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-15
Last Update Date:2025-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4570374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula