Provider Demographics
NPI:1386101434
Name:MACK, TIFFANY NICOLE
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:NICOLE
Last Name:MACK
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 1:6310 27TH AVE N APT 222
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55427-3045
Mailing Address - Country:US
Mailing Address - Phone:651-248-1524
Mailing Address - Fax:
Practice Address - Street 1:6310 27TH AVE N APT 222
Practice Address - Street 2:
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55427-3045
Practice Address - Country:US
Practice Address - Phone:651-248-1524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2468809163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse