Provider Demographics
NPI:1366302812
Name:ELLIS, TIFFANY MEGAN
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MEGAN
Last Name:ELLIS
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 1:259 E 182ND ST APT 19
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-1122
Mailing Address - Country:US
Mailing Address - Phone:570-582-3454
Mailing Address - Fax:570-582-3454
Practice Address - Street 1:2811 QUEENS PLZ N
Practice Address - Street 2:
Practice Address - City:LONG ISLAND CITY
Practice Address - State:NY
Practice Address - Zip Code:11101-4172
Practice Address - Country:US
Practice Address - Phone:718-391-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-11-17
Last Update Date:2025-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN14620-01163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty