Healthcare Provider Details

I. General information

NPI: 1063943173
Provider Name (Legal Business Name): TIFFANY CHANCE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2017
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52D MEDICAL GROUP 550 RED CROSS LP
APO AE
09126
US

IV. Provider business mailing address

PSC 9 BOX 4462
APO AE
09123-0045
US

V. Phone/Fax

Practice location:
  • Phone: 314-452-3167
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN-2243
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberAPRN-2243
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: