Provider Demographics
NPI:1336940634
Name:LUCAS, TIFFANY (AGNP-C)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:LUCAS
Suffix:
Gender:
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 LONG WOOD RD
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36609-5258
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1617 LONG WOOD RD
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36609-5258
Practice Address - Country:US
Practice Address - Phone:251-767-9167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-22
Last Update Date:2025-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALAG02250066363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care