Provider Demographics
NPI:1619784022
Name:STEVENS, TIFFAINE (CHW)
Entity type:Individual
Prefix:
First Name:TIFFAINE
Middle Name:
Last Name:STEVENS
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 COUNTY ROAD 1304
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75501-2244
Mailing Address - Country:US
Mailing Address - Phone:479-799-9740
Mailing Address - Fax:
Practice Address - Street 1:35 COUNTY ROAD 1304
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75501-2244
Practice Address - Country:US
Practice Address - Phone:479-799-9740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-18
Last Update Date:2024-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX12277172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker