Provider Demographics
NPI:1255639001
Name:KIRCHNER, TIFFANY J (CNS)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:J
Last Name:KIRCHNER
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:J
Other - Last Name:WOLFGRAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11104 PARKVIEW CIRCLE DR STE 10
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1733
Practice Address - Country:US
Practice Address - Phone:260-425-6800
Practice Address - Fax:260-425-6845
Is Sole Proprietor?:No
Enumeration Date:2011-03-03
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006850A364SA2200X, 364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1255639001Medicaid
WI1255639001Medicaid
WI73601 2221Medicare PIN