Provider Demographics
NPI:1740765205
Name:WILSON, TIFFANY CELESTE (NP-C)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:CELESTE
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S MAIN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:SEARCY
Mailing Address - State:AR
Mailing Address - Zip Code:72143-7801
Mailing Address - Country:US
Mailing Address - Phone:501-368-0132
Mailing Address - Fax:501-368-0123
Practice Address - Street 1:400 S MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:SEARCY
Practice Address - State:AR
Practice Address - Zip Code:72143-7801
Practice Address - Country:US
Practice Address - Phone:501-368-0132
Practice Address - Fax:501-368-0123
Is Sole Proprietor?:No
Enumeration Date:2018-10-01
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005849363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily