Provider Demographics
NPI:1598832396
Name:DESIMONE, TIFFANY SIMPSON (APRN)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:SIMPSON
Last Name:DESIMONE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MISS
Other - First Name:TIFFANY
Other - Middle Name:L
Other - Last Name:SIMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:9113 LEESGATE RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-5003
Mailing Address - Country:US
Mailing Address - Phone:502-426-1621
Mailing Address - Fax:502-426-7906
Practice Address - Street 1:9113 LEESGATE RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40222-5003
Practice Address - Country:US
Practice Address - Phone:502-426-1621
Practice Address - Fax:502-426-7906
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY5060P363LF0000X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY50015028OtherPASSPORT
KY3005060POtherAPRN LICENSE
IN200853030Medicaid
KY000000501202OtherANTHEM
KY78017936Medicaid
KYQ76732Medicare UPIN
IN200853030Medicaid