MEDICARE: TIFFANY S YOUNG RN, CPNP-PC

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	163W00000X	Registered Nurse	841192-01	NY
2	163W00000X	Registered Nurse	RN2348486	MA
3	363LP0200X	Pediatric Nurse Practitioner	F383507	NY

General Provider Information

NPI Number	:	1982324026
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY S YOUNG RN, CPNP-PC

Provider Business Mailing Address
First Line	:	380 W ELM ST
Second Line	:
City	:	BROCKTON
State	:	MA
Zip	:	02301-4150
Country	:	US
Telephone Number	:	508-468-4114
Fax Number	:

Provider Business Practice Location Address
First Line	:	1322 CORTELYOU RD
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11226-5604
Country	:	US
Telephone Number	:	718-213-4738
Fax Number	:

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

Provider Enumeration Date	:	08/30/2022
Last Update Date	:	01/09/2023

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