Provider Demographics
NPI:1508500760
Name:TAYLOR-MDUBA, TIFFANY SIDRA (APRN)
Entity Type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:SIDRA
Last Name:TAYLOR-MDUBA
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:SIDRA
Other - Last Name:MDUBA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7760 BALSA AVE
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-8500
Mailing Address - Country:US
Mailing Address - Phone:267-648-0351
Mailing Address - Fax:
Practice Address - Street 1:58375 TWENTYNINE PALMS HWY
Practice Address - Street 2:SUITE B
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284
Practice Address - Country:US
Practice Address - Phone:760-365-9305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-25
Last Update Date:2022-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA818748163W00000X
CA95020695363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse