Provider Demographics
NPI:1710539051
Name:FARNSWORTH, TIFFANY (RN)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:FARNSWORTH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, APRN, PMHNP
Mailing Address - Street 1:4641 FULTON DR NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44718-2384
Mailing Address - Country:US
Mailing Address - Phone:330-433-6075
Mailing Address - Fax:
Practice Address - Street 1:4641 FULTON DR NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44718-2384
Practice Address - Country:US
Practice Address - Phone:330-433-6075
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-16
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCNP.0029275363LP0808X
OH398381163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0455901Medicaid