Provider Demographics
NPI:1558436774
Name:PELLATHY, TIFFANY D (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:D
Last Name:PELLATHY
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MRS
Other - First Name:TIFFANY
Other - Middle Name:D
Other - Last Name:PURCELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:3000 VILLAGE RUN RD
Mailing Address - Street 2:BLDG. 103-202
Mailing Address - City:WEXFORD
Mailing Address - State:PA
Mailing Address - Zip Code:15090-6315
Mailing Address - Country:US
Mailing Address - Phone:412-867-9585
Mailing Address - Fax:
Practice Address - Street 1:3000 VILLAGE RUN RD
Practice Address - Street 2:BLDG. 103-202
Practice Address - City:WEXFORD
Practice Address - State:PA
Practice Address - Zip Code:15090-6315
Practice Address - Country:US
Practice Address - Phone:412-867-9585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2011-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC000410363LA2100X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD415096100Medicaid
MD415096100Medicaid