Provider Demographics
NPI:1952866063
Name:WILLIAMS, TIFFANY ANN (FNP-C)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ANN
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:98 POPLAR ST
Mailing Address - Street 2:
Mailing Address - City:BLACKFOOT
Mailing Address - State:ID
Mailing Address - Zip Code:83221-1758
Mailing Address - Country:US
Mailing Address - Phone:208-745-4100
Mailing Address - Fax:
Practice Address - Street 1:1223 CABIN CV
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-8298
Practice Address - Country:US
Practice Address - Phone:208-251-8099
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-02
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID60627363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily