Provider Demographics
NPI:1770919722
Name:WILSON, TIFFANY LAUREN (HIS)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LAUREN
Last Name:WILSON
Suffix:
Gender:F
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 N COMMONS DR STE 200
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-7940
Mailing Address - Country:US
Mailing Address - Phone:630-303-5380
Mailing Address - Fax:630-303-5385
Practice Address - Street 1:1370 PABST FARMS CIR UNIT 330
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4879
Practice Address - Country:US
Practice Address - Phone:262-567-7639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-23
Last Update Date:2024-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1354-060237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist