Provider Demographics
NPI:1760849343
Name:GRAMBLIN, TIFFANY J (ARNP)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:J
Last Name:GRAMBLIN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 KENYON RD STE A
Mailing Address - Street 2:
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-5740
Mailing Address - Country:US
Mailing Address - Phone:515-574-8484
Mailing Address - Fax:
Practice Address - Street 1:1000 10TH AVE
Practice Address - Street 2:
Practice Address - City:ACKLEY
Practice Address - State:IA
Practice Address - Zip Code:50601-1701
Practice Address - Country:US
Practice Address - Phone:641-847-2625
Practice Address - Fax:641-847-2509
Is Sole Proprietor?:No
Enumeration Date:2016-01-27
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA115619363LF0000X
IAA115819363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1124396387OtherTRIMARK PHYSICIANS GROUP NPI
IA1124396387OtherTRIMARK PHYSICIANS GROUP NPI