Provider Demographics
NPI:1922480599
Name:LILES, TIFFANY (APRN)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:LILES
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7406 FULLERTON ST STE 105
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-3588
Mailing Address - Country:US
Mailing Address - Phone:778-684-8278
Mailing Address - Fax:
Practice Address - Street 1:10151 DEERWOOD PARK BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32256-0566
Practice Address - Country:US
Practice Address - Phone:904-252-6284
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-19
Last Update Date:2020-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN9457993363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVV111206Medicare PIN