Provider Demographics
NPI:1346584257
Name:YOUNG, TIFFANY (RN)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:YOUNG
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7210 N PORT WASHINGTON RD
Mailing Address - Street 2:3
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53217-3413
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7210 N PORT WASHINGTON RD
Practice Address - Street 2:3
Practice Address - City:GLENDALE
Practice Address - State:WI
Practice Address - Zip Code:53217-3413
Practice Address - Country:US
Practice Address - Phone:219-712-8561
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI191926-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse