Provider Demographics
NPI:1639540685
Name:MAGALLANES, TIFFANY (MS, CPNP)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:MAGALLANES
Suffix:
Gender:F
Credentials:MS, CPNP
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:
Other - Last Name:STODDARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS CPNP
Mailing Address - Street 1:2050 S BLOSSER RD
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-7310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2801 SANTA MARIA WAY
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93455-2118
Practice Address - Country:US
Practice Address - Phone:805-934-5400
Practice Address - Fax:805-938-9207
Is Sole Proprietor?:No
Enumeration Date:2015-10-16
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95004127363LP0200X
CO0991941363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics