Provider Demographics
NPI:1093054975
Name:NICHOLSON, TIFFANY (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 ALDINE ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14619-1204
Mailing Address - Country:US
Mailing Address - Phone:585-208-7771
Mailing Address - Fax:
Practice Address - Street 1:1 JOHN JAMES AUDUBON PKWY STE 200
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14228-1145
Practice Address - Country:US
Practice Address - Phone:716-204-4500
Practice Address - Fax:585-672-2527
Is Sole Proprietor?:No
Enumeration Date:2013-02-12
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY605019163WC1500X
NY308982363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health