Provider Demographics
NPI:1457823056
Name:GARDNER, TIFFANY HICKS (APRN)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:HICKS
Last Name:GARDNER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 423
Mailing Address - Street 2:
Mailing Address - City:CARRIER MILLS
Mailing Address - State:IL
Mailing Address - Zip Code:62917-0423
Mailing Address - Country:US
Mailing Address - Phone:618-499-2307
Mailing Address - Fax:
Practice Address - Street 1:1155 CEDAR CT
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-5333
Practice Address - Country:US
Practice Address - Phone:618-490-1045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-19
Last Update Date:2018-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209017781363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily