Healthcare Provider Details

I. General information

NPI: 1447658802
Provider Name (Legal Business Name): TIFFANY LAUREN DEAN NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2014
Last Update Date: 07/06/2020
Certification Date: 07/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18TH MEDICAL GROUP
APO AP
96368-5142
US

IV. Provider business mailing address

BUILDING 626 DOUGLAS DR
KADENA AB OKINAWA
96367
JP

V. Phone/Fax

Practice location:
  • Phone: 315-630-4542
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number875782
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: