Provider Demographics
NPI:1083203665
Name:COLSTON, TIFFANY M (MSN, APRN)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:M
Last Name:COLSTON
Suffix:
Gender:F
Credentials:MSN, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3900 W WILLOW BEACH RD
Mailing Address - Street 2:
Mailing Address - City:PORT CLINTON
Mailing Address - State:OH
Mailing Address - Zip Code:43452-9369
Mailing Address - Country:US
Mailing Address - Phone:419-707-0892
Mailing Address - Fax:
Practice Address - Street 1:619 FULTON ST
Practice Address - Street 2:
Practice Address - City:PORT CLINTON
Practice Address - State:OH
Practice Address - Zip Code:43452-2069
Practice Address - Country:US
Practice Address - Phone:419-732-2614
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-18
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLE-00035116363LA2200X
OHAPRN.CNP.0028286363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health