Provider Demographics
NPI:1619670908
Name:HOLDER, TIFFANY LYNN (APRN)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:LYNN
Last Name:HOLDER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14341 COUNTY ROAD 3585
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-5311
Mailing Address - Country:US
Mailing Address - Phone:580-421-5161
Mailing Address - Fax:
Practice Address - Street 1:14341 COUNTY ROAD 3585
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-5311
Practice Address - Country:US
Practice Address - Phone:580-421-5161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-24
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK211620363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner