Provider Demographics
NPI:1679019301
Name:PORTER, TIFFANY J (FNP)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:J
Last Name:PORTER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:
Other - Last Name:NITTI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:1301 FOX MEADOW CT
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-1670
Mailing Address - Country:US
Mailing Address - Phone:630-915-8693
Mailing Address - Fax:
Practice Address - Street 1:12200 WESTERN AVE
Practice Address - Street 2:
Practice Address - City:BLUE ISLAND
Practice Address - State:IL
Practice Address - Zip Code:60406-1398
Practice Address - Country:US
Practice Address - Phone:630-581-5372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-19
Last Update Date:2019-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209015112364SF0001X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health