Provider Demographics
NPI:1710751813
Name:MENNEN, TIFFANY LYNN
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LYNN
Last Name:MENNEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2830 E DIETZEN DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54915-6616
Mailing Address - Country:US
Mailing Address - Phone:920-284-6513
Mailing Address - Fax:
Practice Address - Street 1:2725 JACKSON ST
Practice Address - Street 2:
Practice Address - City:OSHKOSH
Practice Address - State:WI
Practice Address - Zip Code:54901-1513
Practice Address - Country:US
Practice Address - Phone:920-223-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-08
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI14118-33363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily