Provider Demographics
NPI:1477877157
Name:WILSON, TIFFANY
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:WILSON
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 1:2221 E NORTHERN LIGHTS BLVD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99508-4103
Mailing Address - Country:US
Mailing Address - Phone:907-562-7019
Mailing Address - Fax:907-344-7284
Practice Address - Street 1:2221 E NORTHERN LIGHTS BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-4103
Practice Address - Country:US
Practice Address - Phone:907-562-7019
Practice Address - Fax:907-344-7284
Is Sole Proprietor?:No
Enumeration Date:2010-03-24
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator