Provider Demographics
NPI:1811756844
Name:LEE, TIFFANY GAYLE (CPNP-PC)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:GAYLE
Last Name:LEE
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 FIFTH AVE
Mailing Address - Street 2:
Mailing Address - City:PICAYUNE
Mailing Address - State:MS
Mailing Address - Zip Code:39466-3203
Mailing Address - Country:US
Mailing Address - Phone:504-619-9733
Mailing Address - Fax:
Practice Address - Street 1:517 FIFTH AVE
Practice Address - Street 2:
Practice Address - City:PICAYUNE
Practice Address - State:MS
Practice Address - Zip Code:39466-3203
Practice Address - Country:US
Practice Address - Phone:601-799-5865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-13
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA234680363LP2300X
MS906493363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care