Provider Demographics
NPI:1104803543
Name:CERVENAK, TIFFANY ANN (NP)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ANN
Last Name:CERVENAK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3080 BRISTOL ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-3093
Mailing Address - Country:US
Mailing Address - Phone:714-445-0220
Mailing Address - Fax:714-445-0245
Practice Address - Street 1:24012 CALLE DE LA PLATA
Practice Address - Street 2:SUITE 150
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-3621
Practice Address - Country:US
Practice Address - Phone:949-837-1578
Practice Address - Fax:949-837-8154
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-28
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CA10177363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner