Provider Demographics
NPI:1093532798
Name:PRATER, TIFFANY NICOLE
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:NICOLE
Last Name:PRATER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9316 DEER PATH LN
Mailing Address - Street 2:
Mailing Address - City:KERNERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27284-8204
Mailing Address - Country:US
Mailing Address - Phone:502-316-3279
Mailing Address - Fax:
Practice Address - Street 1:9316 DEER PATH LN
Practice Address - Street 2:
Practice Address - City:KERNERSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27284-8204
Practice Address - Country:US
Practice Address - Phone:502-316-3279
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY104561320163WM0102X
KY1131690163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn