Provider Demographics
NPI:1922556612
Name:BENNETT, TIFFANY L (CRNP)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:L
Last Name:BENNETT
Suffix:
Gender:F
Credentials:CRNP
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 1671
Mailing Address - Street 2:
Mailing Address - City:CUMBERLAND
Mailing Address - State:MD
Mailing Address - Zip Code:21501-1671
Mailing Address - Country:US
Mailing Address - Phone:240-964-8585
Mailing Address - Fax:240-964-8586
Practice Address - Street 1:12502 WILLOWBROOK RD STE 380
Practice Address - Street 2:
Practice Address - City:CUMBERLAND
Practice Address - State:MD
Practice Address - Zip Code:21502-6592
Practice Address - Country:US
Practice Address - Phone:240-964-8585
Practice Address - Fax:240-964-8586
Is Sole Proprietor?:No
Enumeration Date:2016-09-12
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR163851363LP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR163851OtherMARYLAND BOARD OF NURSING