Provider Demographics
NPI:1427087857
Name:BARTOLAC, TIFFANI SANDRA (APRN)
Entity type:Individual
Prefix:MRS
First Name:TIFFANI
Middle Name:SANDRA
Last Name:BARTOLAC
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:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-426-0800
Mailing Address - Fax:859-426-4140
Practice Address - Street 1:711 MEDICAL VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3439
Practice Address - Country:US
Practice Address - Phone:859-331-0774
Practice Address - Fax:859-578-3800
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247200000X
OHAPRN CNP 019769363LF0000X
KY3012078363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY184607OtherMEDICARE GROUP NUMBER
KY610661458OtherFEDERAL TAX ID NUMBER