Provider Demographics
NPI:1578936811
Name:WAGUESPACK, TIFFANY (WHNP-BC)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:WAGUESPACK
Suffix:
Gender:F
Credentials:WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:605 WILLOW ST
Mailing Address - Street 2:
Mailing Address - City:MORGAN CITY
Mailing Address - State:LA
Mailing Address - Zip Code:70380-2651
Mailing Address - Country:US
Mailing Address - Phone:985-518-4263
Mailing Address - Fax:
Practice Address - Street 1:1151 MARGUERITE ST
Practice Address - Street 2:STE 700A
Practice Address - City:MORGAN CITY
Practice Address - State:LA
Practice Address - Zip Code:70380-1850
Practice Address - Country:US
Practice Address - Phone:985-221-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-09
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP08550363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health