Provider Demographics
NPI:1457784811
Name:BACCHUS, TIFFANY R (FNP)
Entity Type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:R
Last Name:BACCHUS
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 1:181 HAWTHORNE ST
Mailing Address - Street 2:APT 1F
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11225-5862
Mailing Address - Country:US
Mailing Address - Phone:646-320-8037
Mailing Address - Fax:
Practice Address - Street 1:506 6TH ST
Practice Address - Street 2:6TH FLOOR
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11215-3609
Practice Address - Country:US
Practice Address - Phone:718-780-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-20
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF337613-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily