Healthcare Provider Details

I. General information

NPI: 1255995692
Provider Name (Legal Business Name): DEIRDRA TIFFANY FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2019
Last Update Date: 04/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2041 MARTIN LUTHER KING JR AVE SE STE 303
WASHINGTON DC
20020-7036
US

IV. Provider business mailing address

924 T ST NW APT A
WASHINGTON DC
20001-4120
US

V. Phone/Fax

Practice location:
  • Phone: 202-889-7900
  • Fax:
Mailing address:
  • Phone: 301-904-0429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1040003
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: