Provider Demographics
NPI:1396306163
Name:RUSSELL, TIFFANIE (FNP)
Entity type:Individual
Prefix:
First Name:TIFFANIE
Middle Name:
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3566 E IVANHOE ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-3498
Mailing Address - Country:US
Mailing Address - Phone:480-907-4094
Mailing Address - Fax:
Practice Address - Street 1:2730 S VAL VISTA DR STE 138
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85295-1681
Practice Address - Country:US
Practice Address - Phone:480-686-9686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-24
Last Update Date:2019-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRNP227754363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZRNP227754OtherARIZONA STATE BOARD OF NURSING