Provider Demographics
NPI:1346646221
Name:PEARSON, TIFFANY RENEE
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:RENEE
Last Name:PEARSON
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 1:2005 LAUREL CT
Mailing Address - Street 2:
Mailing Address - City:NORTH BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-2738
Mailing Address - Country:US
Mailing Address - Phone:516-633-8326
Mailing Address - Fax:
Practice Address - Street 1:2005 LAUREL CT
Practice Address - Street 2:
Practice Address - City:NORTH BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-2738
Practice Address - Country:US
Practice Address - Phone:516-633-8326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-05
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY320501164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse