Provider Demographics
NPI:1386166411
Name:STEWART, TIFFANY NICOLE (APRN)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:NICOLE
Last Name:STEWART
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 S UNION ST. PETERSBURG, VA 23803
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:23139-5002
Mailing Address - Country:US
Mailing Address - Phone:479-586-2335
Mailing Address - Fax:
Practice Address - Street 1:25 S UNION ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-4221
Practice Address - Country:US
Practice Address - Phone:479-586-2335
Practice Address - Fax:804-957-5850
Is Sole Proprietor?:No
Enumeration Date:2017-07-11
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005246363LP2300X
VA0024183941363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care