Healthcare Provider Details

I. General information

NPI: 1295323913
Provider Name (Legal Business Name): TIFFANY LYNNE BROKAW RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/07/2021
Last Update Date: 01/07/2021
Certification Date: 01/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

411 TANGLEWOOD CT
PASO ROBLES CA
93446-4486
US

IV. Provider business mailing address

411 TANGLEWOOD CT
PASO ROBLES CA
93446-4486
US

V. Phone/Fax

Practice location:
  • Phone: 805-540-8452
  • Fax:
Mailing address:
  • Phone: 805-540-8452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number462035
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: