Provider Demographics
NPI:1164082517
Name:HUMPHREY, TIFFANY (APRN)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:KY
Mailing Address - Zip Code:42220-0187
Mailing Address - Country:US
Mailing Address - Phone:270-265-2574
Mailing Address - Fax:
Practice Address - Street 1:105 ELK FORK RD
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:KY
Practice Address - Zip Code:42220-7218
Practice Address - Country:US
Practice Address - Phone:270-265-2574
Practice Address - Fax:270-265-3098
Is Sole Proprietor?:No
Enumeration Date:2019-06-18
Last Update Date:2020-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3013467363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily