Provider Demographics
NPI:1063853653
Name:MINNICK, TIFFANY LYNN (CRNA)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LYNN
Last Name:MINNICK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:LYNN
Other - Last Name:AMATENDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:4135 BOARDMAN CANFIELD RD STE 101
Mailing Address - Street 2:
Mailing Address - City:CANFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44406-9803
Mailing Address - Country:US
Mailing Address - Phone:330-286-5330
Mailing Address - Fax:330-286-5396
Practice Address - Street 1:1044 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44504-1006
Practice Address - Country:US
Practice Address - Phone:330-480-3658
Practice Address - Fax:330-480-3439
Is Sole Proprietor?:No
Enumeration Date:2013-07-11
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN622212367500000X
OHAPRNCRNA0020173367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPENDINGMedicaid
OHPENDINGOtherMEDICARE PTAN
13609572OtherCAQH