Provider Demographics
NPI:1447068143
Name:MCCONNELL, TIFFANY RENEE
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:RENEE
Last Name:MCCONNELL
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 1:510 S GAY ST
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:OH
Mailing Address - Zip Code:43845-1440
Mailing Address - Country:US
Mailing Address - Phone:740-610-6955
Mailing Address - Fax:
Practice Address - Street 1:510 S GAY ST
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:OH
Practice Address - Zip Code:43845-1440
Practice Address - Country:US
Practice Address - Phone:740-610-6955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-27
Last Update Date:2024-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH343900000X, 251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)