Provider Demographics
NPI:1043525173
Name:GANNON, TIFFANY (FNP)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:GANNON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 HEALTH WAY STE 2
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37110-2668
Mailing Address - Country:US
Mailing Address - Phone:931-473-4214
Mailing Address - Fax:931-473-0666
Practice Address - Street 1:155 HEALTH WAY STE 2
Practice Address - Street 2:
Practice Address - City:MCMINNVILLE
Practice Address - State:TN
Practice Address - Zip Code:37110-2668
Practice Address - Country:US
Practice Address - Phone:931-473-4214
Practice Address - Fax:931-473-0666
Is Sole Proprietor?:No
Enumeration Date:2010-08-12
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN15121363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner