Provider Demographics
NPI:1518234491
Name:HAYES, TIFFANY LACOLE (MSN, ARNP, FNP-BC)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LACOLE
Last Name:HAYES
Suffix:
Gender:F
Credentials:MSN, ARNP, FNP-BC
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 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:2051 CLEVIDENCE BLVD
Practice Address - Street 2:SUITE 1
Practice Address - City:CLARKSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47129-2278
Practice Address - Country:US
Practice Address - Phone:812-280-9145
Practice Address - Fax:812-280-6627
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-21
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28165938A163W00000X
KY1116764163WE0003X
KY3007179363L00000X, 363LF0000X
IN71003799A363LF0000X
IN71003799B363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No163WE0003XNursing Service ProvidersRegistered NurseEmergency
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY132355OtherSIHO
IN201054410Medicaid
KY000000746934OtherANTHEM - NICC
KYK029950Medicare PIN
KY132355OtherSIHO