Healthcare Provider Details

I. General information

NPI: 1174343883
Provider Name (Legal Business Name): AESTHETICA PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2024
Last Update Date: 10/16/2024
Certification Date: 10/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 E MONTEREY WAY STE 202
PHOENIX AZ
85012-2757
US

IV. Provider business mailing address

45 E MONTEREY WAY STE 202
PHOENIX AZ
85012-2757
US

V. Phone/Fax

Practice location:
  • Phone: 602-791-0199
  • Fax:
Mailing address:
  • Phone: 602-791-0199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. TIFFANY HARRIS
Title or Position: OWNER/CEO
Credential: PHD, CMOT, CSCS
Phone: 602-791-0199