Provider Demographics
NPI:1871127514
Name:DICKERSON, TIFFANI (RN-IBCLC)
Entity type:Individual
Prefix:MRS
First Name:TIFFANI
Middle Name:
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:RN-IBCLC
Other - Prefix:
Other - First Name:TIFFANI
Other - Middle Name:
Other - Last Name:ROQUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1636 N HAMPTON RD STE 227
Mailing Address - Street 2:
Mailing Address - City:DESOTO
Mailing Address - State:TX
Mailing Address - Zip Code:75115-8601
Mailing Address - Country:US
Mailing Address - Phone:972-765-8195
Mailing Address - Fax:
Practice Address - Street 1:1636 N HAMPTON RD STE 227
Practice Address - Street 2:
Practice Address - City:DESOTO
Practice Address - State:TX
Practice Address - Zip Code:75115-8601
Practice Address - Country:US
Practice Address - Phone:972-765-8195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-02
Last Update Date:2025-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
TX764609163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No171M00000XOther Service ProvidersCase Manager/Care Coordinator