Healthcare Provider Details

I. General information

NPI: 1053169219
Provider Name (Legal Business Name): TIFFANY DARLENE AUTREY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TIFFANY DARLENE WATSON

II. Dates (important events)

Enumeration Date: 05/10/2024
Last Update Date: 05/10/2024
Certification Date: 02/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1637 N 66TH ST
MESA AZ
85205-3741
US

IV. Provider business mailing address

1637 N 66TH ST
MESA AZ
85205-3741
US

V. Phone/Fax

Practice location:
  • Phone: 951-581-0998
  • Fax:
Mailing address:
  • Phone: 951-581-0998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number305685
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN209925
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: