Provider Demographics
NPI:1659495265
Name:COBB, TIFFANY R (RN)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:R
Last Name:COBB
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6863 N 41ST ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2202
Mailing Address - Country:US
Mailing Address - Phone:414-517-6073
Mailing Address - Fax:
Practice Address - Street 1:2616 N 90TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-1813
Practice Address - Country:US
Practice Address - Phone:414-475-6224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI152939163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35009700Medicare ID - Type UnspecifiedPROVIDER NUMBER