Healthcare Provider Details

I. General information

NPI: 1770083198
Provider Name (Legal Business Name): TIFFANY GRACE MONTICINO FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2018
Last Update Date: 02/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 WASHINGTON ST STE 600
SAN DIEGO CA
92103-2239
US

IV. Provider business mailing address

4478 CAMPUS AVE APT 101
SAN DIEGO CA
92116-3954
US

V. Phone/Fax

Practice location:
  • Phone: 619-278-3300
  • Fax:
Mailing address:
  • Phone: 619-677-0364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License Number518794
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number518794
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number518794
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: