Provider Demographics
NPI:1093446957
Name:CERENECHE, MARY TIFFANY (NP-C)
Entity Type:Individual
Prefix:
First Name:MARY TIFFANY
Middle Name:
Last Name:CERENECHE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:MARY TIFFANY
Other - Middle Name:DARA
Other - Last Name:CERENECHE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP-C
Mailing Address - Street 1:25 SILKBERRY
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-7480
Mailing Address - Country:US
Mailing Address - Phone:757-618-3763
Mailing Address - Fax:
Practice Address - Street 1:333 THALIA ST
Practice Address - Street 2:
Practice Address - City:LAGUNA BEACH
Practice Address - State:CA
Practice Address - Zip Code:92651-2713
Practice Address - Country:US
Practice Address - Phone:949-499-0577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-22
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95019956363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care