Provider Demographics
NPI:1376323469
Name:WENCK, TIFFANI B (NP)
Entity Type:Individual
Prefix:
First Name:TIFFANI
Middle Name:B
Last Name:WENCK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TIFFANI
Other - Middle Name:B
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:355 W 16TH ST STE 5100
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2274
Practice Address - Country:US
Practice Address - Phone:317-963-1300
Practice Address - Fax:317-222-2012
Is Sole Proprietor?:No
Enumeration Date:2023-10-05
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71014426A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily