MEDICARE: TIFFANY LEANN CARR FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	104539	WV

General Provider Information

NPI Number	:	1174173835
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY LEANN CARR FNP-BC

Provider Business Mailing Address
First Line	:	357 KENNEDY ST
Second Line	:
City	:	ELKINS
State	:	WV
Zip	:	26241-5257
Country	:	US
Telephone Number	:	304-704-8135
Fax Number	:

Provider Business Practice Location Address
First Line	:	55 CHENOWETH CREEK RD
Second Line	:
City	:	ELKINS
State	:	WV
Zip	:	26241-9237
Country	:	US
Telephone Number	:	304-637-5006
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2019
Last Update Date	:	09/16/2019

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