Provider Demographics
NPI:1255679171
Name:ROSE, TIFFANI (CNP)
Entity Type:Individual
Prefix:MS
First Name:TIFFANI
Middle Name:
Last Name:ROSE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4580 COMMONS PARK DR
Mailing Address - Street 2:
Mailing Address - City:NEW ALBANY
Mailing Address - State:OH
Mailing Address - Zip Code:43054-8699
Mailing Address - Country:US
Mailing Address - Phone:614-710-0727
Mailing Address - Fax:614-710-0077
Practice Address - Street 1:4580 COMMONS PARK DR
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:OH
Practice Address - Zip Code:43054-8699
Practice Address - Country:US
Practice Address - Phone:614-710-0077
Practice Address - Fax:614-710-0077
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-28
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN267314163W00000X
OHCOA.17574-NP363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0088547Medicaid
OH0088547Medicaid