Provider Demographics
NPI:1982324026
Name:YOUNG, TIFFANY S (RN, CPNP-PC)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:S
Last Name:YOUNG
Suffix:
Gender:F
Credentials:RN, CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:380 W ELM ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-4150
Mailing Address - Country:US
Mailing Address - Phone:508-468-4114
Mailing Address - Fax:
Practice Address - Street 1:1322 CORTELYOU RD
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11226-5604
Practice Address - Country:US
Practice Address - Phone:718-213-4738
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-30
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY841192-01163W00000X
MARN2348486163W00000X
NYF383507363LP0200X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163W00000XNursing Service ProvidersRegistered Nurse