Provider Demographics
NPI:1013480854
Name:TIFFT, KESTA
Entity type:Individual
Prefix:
First Name:KESTA
Middle Name:
Last Name:TIFFT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 FARNSWORTH DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45449-2129
Mailing Address - Country:US
Mailing Address - Phone:937-829-5488
Mailing Address - Fax:
Practice Address - Street 1:1625 DELCO PARK DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45420-1391
Practice Address - Country:US
Practice Address - Phone:937-535-2200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.332552163W00000X
OHLE-00026839363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse