Provider Demographics
NPI:1700376688
Name:DAMON, TIFFANY CHERE (NP)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:CHERE
Last Name:DAMON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:CHERE
Other - Last Name:HAYNER-RUSSELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:20 APRICOT LN
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090-2333
Practice Address - Country:US
Practice Address - Phone:315-767-7941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYUNKNOWN363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner