Provider Demographics
NPI:1801201439
Name:BRUCKNER, TIFFANY (CNP)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:BRUCKNER
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:
Other - Last Name:MOORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1460
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57402-1460
Mailing Address - Country:US
Mailing Address - Phone:605-622-2857
Mailing Address - Fax:605-622-2859
Practice Address - Street 1:201 S LLOYD ST STE E201
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401-4509
Practice Address - Country:US
Practice Address - Phone:605-622-2545
Practice Address - Fax:605-229-5331
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP000859363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner