Provider Demographics
NPI:1124490008
Name:DIESO, TIFFANY HERMAN (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:HERMAN
Last Name:DIESO
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5213 S ALSTON AVE
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-4430
Mailing Address - Country:US
Mailing Address - Phone:919-620-4855
Mailing Address - Fax:
Practice Address - Street 1:40 MEDICINE CIR
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27710-0001
Practice Address - Country:US
Practice Address - Phone:919-385-7941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-30
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC246947363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care