Provider Demographics
NPI:1770018095
Name:BRUNSON, TIFFANY (FNP-C)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:BRUNSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 RIPPLE WAY UNIT 2301
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-6601
Mailing Address - Country:US
Mailing Address - Phone:843-992-9415
Mailing Address - Fax:
Practice Address - Street 1:9915 PARK CEDAR DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8905
Practice Address - Country:US
Practice Address - Phone:704-544-3263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-24
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20898363LF0000X
NC5011708363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily