Provider Demographics
NPI:1013169267
Name:WOOD, TIFFANY RAEANN (RN)
Entity type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:RAEANN
Last Name:WOOD
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:TIFFANY
Other - Middle Name:RAEANN
Other - Last Name:WENTWORTH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:6559 WISE LAKE ROAD
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-6051
Mailing Address - Country:US
Mailing Address - Phone:218-828-1963
Mailing Address - Fax:
Practice Address - Street 1:106 4TH AVENUE NORTH
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-1034
Practice Address - Country:US
Practice Address - Phone:218-998-3778
Practice Address - Fax:218-998-3187
Is Sole Proprietor?:No
Enumeration Date:2008-10-21
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-175193-4163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse