Provider Demographics
NPI:1669783007
Name:LEE, TIFFANEY KRYSTAL (LPN)
Entity type:Individual
Prefix:
First Name:TIFFANEY
Middle Name:KRYSTAL
Last Name:LEE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:743 W BROWN ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53205-1304
Mailing Address - Country:US
Mailing Address - Phone:414-517-9015
Mailing Address - Fax:
Practice Address - Street 1:743 W BROWN ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53205-1304
Practice Address - Country:US
Practice Address - Phone:414-517-9015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-30
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI306948-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI$$$$$$$$$Medicaid