Provider Demographics
NPI:1780672451
Name:BOAN, TIFFANY LYNNE (FNP)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LYNNE
Last Name:BOAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8560 COOK ST
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:NC
Practice Address - Zip Code:28124-7686
Practice Address - Country:US
Practice Address - Phone:704-436-6521
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5000948363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7003770Medicaid
NC2592472AMedicare PIN