Provider Demographics
NPI:1700018769
Name:LAGE, TIFFANY KAY (LPN)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:KAY
Last Name:LAGE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21233 N 79TH DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-4454
Mailing Address - Country:US
Mailing Address - Phone:623-313-2342
Mailing Address - Fax:
Practice Address - Street 1:21233 N 79TH DR
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-4454
Practice Address - Country:US
Practice Address - Phone:623-313-2342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-10
Last Update Date:2009-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLP044259164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse