Provider Demographics
NPI:1811313877
Name:WALTON, TIFFANY MARIE (LPN)
Entity type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:MARIE
Last Name:WALTON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:MARIE
Other - Last Name:WALTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:149 VIRGIL AVE
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14216-1805
Mailing Address - Country:US
Mailing Address - Phone:716-936-1873
Mailing Address - Fax:
Practice Address - Street 1:149 VIRGIL AVE
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14216-1805
Practice Address - Country:US
Practice Address - Phone:716-936-1873
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-13
Last Update Date:2015-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY10304898164W00000X
NY22685068163WC0400X, 163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03810262Medicaid