Provider Demographics
NPI:1588035018
Name:DOUGLAS, TIFFANY
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 VARICK ST FL 5
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-1917
Mailing Address - Country:US
Mailing Address - Phone:855-961-1942
Mailing Address - Fax:866-702-0882
Practice Address - Street 1:75 VARICK ST FL 5
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10013-1917
Practice Address - Country:US
Practice Address - Phone:855-961-1942
Practice Address - Fax:866-702-0882
Is Sole Proprietor?:No
Enumeration Date:2015-10-09
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5012697363L00000X
SC26784363L00000X
GARN270965363LF0000X
MARN2299504363LF0000X
FL11034085363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner