Provider Demographics
NPI:1386805034
Name:NUNNELLEY, TIFFANY A (DO)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:A
Last Name:NUNNELLEY
Suffix:
Gender:F
Credentials:DO
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Mailing Address - Street 1:8620 N 22ND AVE
Mailing Address - Street 2:200
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-4251
Mailing Address - Country:US
Mailing Address - Phone:602-674-6506
Mailing Address - Fax:602-674-6512
Practice Address - Street 1:6036 N 19TH AVE
Practice Address - Street 2:505
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015
Practice Address - Country:US
Practice Address - Phone:602-841-0721
Practice Address - Fax:602-841-0729
Is Sole Proprietor?:No
Enumeration Date:2008-06-24
Last Update Date:2009-12-16
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Provider Licenses
StateLicense IDTaxonomies
AZ4788207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ438727Medicaid
AZZ131818Medicare PIN