Provider Demographics
NPI:1346752847
Name:NIELSEN, TIFFANY NICOLE (PT)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:NICOLE
Last Name:NIELSEN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 E BOXELDER RD STE U
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-5582
Mailing Address - Country:US
Mailing Address - Phone:307-686-8177
Mailing Address - Fax:307-686-9484
Practice Address - Street 1:1103 E BOXELDER RD STE U
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718
Practice Address - Country:US
Practice Address - Phone:307-686-8177
Practice Address - Fax:307-686-9484
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-25
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY1498225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty