Provider Demographics
NPI:1578007571
Name:WATSON, TIFFANY (CNP)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:WATSON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12217 CHAMPLIN DR
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316-1930
Mailing Address - Country:US
Mailing Address - Phone:763-323-1492
Mailing Address - Fax:
Practice Address - Street 1:12217 CHAMPLIN DR
Practice Address - Street 2:
Practice Address - City:CHAMPLIN
Practice Address - State:MN
Practice Address - Zip Code:55316-1930
Practice Address - Country:US
Practice Address - Phone:763-323-1492
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-09
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN186206-9163W00000X
MN4912363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse