Provider Demographics
NPI:1598367328
Name:BAISDEN, TIFANI
Entity Type:Individual
Prefix:
First Name:TIFANI
Middle Name:
Last Name:BAISDEN
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 1:48332 STAPLETON AVE
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48042-5193
Mailing Address - Country:US
Mailing Address - Phone:586-260-8097
Mailing Address - Fax:
Practice Address - Street 1:48332 STAPLETON AVE
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:MI
Practice Address - Zip Code:48042-5193
Practice Address - Country:US
Practice Address - Phone:586-260-8097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704305401363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health