Provider Demographics
NPI:1770083198
Name:MONTICINO, TIFFANY GRACE (FNP-C)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:GRACE
Last Name:MONTICINO
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4478 CAMPUS AVE APT 101
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-3954
Mailing Address - Country:US
Mailing Address - Phone:619-677-0364
Mailing Address - Fax:
Practice Address - Street 1:501 WASHINGTON ST STE 600
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2239
Practice Address - Country:US
Practice Address - Phone:619-278-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-13
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA518794163WC1600X, 163WP0808X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC1600XNursing Service ProvidersRegistered NurseContinuing Education/Staff Development
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA518794OtherCA RN LICENSE
CANPF95007922OtherCA NP FURNISHING LICENSE
CANP95007922OtherCA FNP CERTIFICATION