MEDICARE: TIFFANY MERRILL KETZLE APRN ANP-C

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	363LA2200X	Adult Health Nurse Practitioner	681853	TX
2	363L00000X	Nurse Practitioner	AP111326	TX

General Provider Information

NPI Number	:	1982719837
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY MERRILL KETZLE APRN ANP-C

Provider Business Mailing Address
First Line	:	3901 W 15TH ST
Second Line	:
City	:	PLANO
State	:	TX
Zip	:	75075-7738
Country	:	US
Telephone Number	:	972-867-0129
Fax Number	:

Provider Business Practice Location Address
First Line	:	6513 PRESTON RD
Second Line	:	SUITE 300
City	:	PLANO
State	:	TX
Zip	:	75024-2688
Country	:	US
Telephone Number	:	972-608-2025
Fax Number	:	972-608-2032

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

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	01/04/2022

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