Provider Demographics
NPI:1790121671
Name:GRAY, TIFFANY CHANEL (RN)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:CHANEL
Last Name:GRAY
Suffix:
Gender:F
Credentials:RN
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 6242
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53716-0242
Mailing Address - Country:US
Mailing Address - Phone:608-658-0271
Mailing Address - Fax:
Practice Address - Street 1:211 W MAIN ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:WI
Practice Address - Zip Code:53559-8964
Practice Address - Country:US
Practice Address - Phone:608-658-0271
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-17
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI31404531164W00000X
WI196082 - 30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse