Provider Demographics
NPI:1518393040
Name:WILSON, TIFFANY MARIE (LPN)
Entity Type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 N MCCORD RD # P-172
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43615-8702
Mailing Address - Country:US
Mailing Address - Phone:419-514-9452
Mailing Address - Fax:
Practice Address - Street 1:1800 N MCCORD RD # P-172
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-8702
Practice Address - Country:US
Practice Address - Phone:419-514-9452
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-16
Last Update Date:2017-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH135172164W00000X
MI4703100408164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse