Provider Demographics
NPI:1215438445
Name:STEWART, TIFFANY DESHAN (FNP-C)
Entity type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:DESHAN
Last Name:STEWART
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9000 S TROY AVE
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-1336
Mailing Address - Country:US
Mailing Address - Phone:773-983-3217
Mailing Address - Fax:
Practice Address - Street 1:4415 HARRISON ST STE 247
Practice Address - Street 2:
Practice Address - City:HILLSIDE
Practice Address - State:IL
Practice Address - Zip Code:60162-1919
Practice Address - Country:US
Practice Address - Phone:773-983-3217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL02180108363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily