Provider Demographics
NPI:1154087773
Name:PICKRELL, TIFFANY
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:PICKRELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 SHADY LN S
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:KY
Mailing Address - Zip Code:41002-9311
Mailing Address - Country:US
Mailing Address - Phone:606-748-2116
Mailing Address - Fax:
Practice Address - Street 1:409 SHADY LN S
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:KY
Practice Address - Zip Code:41002-9311
Practice Address - Country:US
Practice Address - Phone:606-748-2116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3016994363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily