Provider Demographics
NPI:1700167822
Name:GONZALO, TIFFANY A (CRNP)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:A
Last Name:GONZALO
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:A
Other - Last Name:GRIMES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5715
Mailing Address - Fax:
Practice Address - Street 1:1229 3RD ST SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4611
Practice Address - Country:US
Practice Address - Phone:540-512-5200
Practice Address - Fax:540-982-7189
Is Sole Proprietor?:No
Enumeration Date:2011-09-02
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP011520363LF0000X
VA0024185508363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily