Provider Demographics
NPI:1376817221
Name:CLACK, TIFFANY LEAH (MSN-ANP)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LEAH
Last Name:CLACK
Suffix:
Gender:F
Credentials:MSN-ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:712 N WASHINGTON AVE
Mailing Address - Street 2:SUITE 415
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75246-1619
Mailing Address - Country:US
Mailing Address - Phone:214-820-9115
Mailing Address - Fax:214-820-9135
Practice Address - Street 1:712 N. WASHINGTON AVE
Practice Address - Street 2:SUITE 415
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75246-1800
Practice Address - Country:US
Practice Address - Phone:214-820-9115
Practice Address - Fax:214-820-9135
Is Sole Proprietor?:No
Enumeration Date:2012-02-23
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX765246363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX294800201Medicaid
TX294800201Medicaid
TXTXB148384Medicare PIN