Provider Demographics
NPI:1588123806
Name:ZICHKO, TIFFANI MARIE (NP)
Entity type:Individual
Prefix:
First Name:TIFFANI
Middle Name:MARIE
Last Name:ZICHKO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:TIFFANI
Other - Middle Name:MARIE
Other - Last Name:CASALENUOVO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:80 VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-6474
Mailing Address - Country:US
Mailing Address - Phone:865-482-4078
Mailing Address - Fax:
Practice Address - Street 1:80 VERMONT AVE
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-6474
Practice Address - Country:US
Practice Address - Phone:865-482-4078
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-16
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN24334363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ053000Medicaid