Healthcare Provider Details

I. General information

NPI: 1093041261
Provider Name (Legal Business Name): TIFFANY CRYSTAL PENN MSN, RN CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2009
Last Update Date: 03/09/2025
Certification Date: 03/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 DENNY CIR
NEWARK DE
19702-5925
US

IV. Provider business mailing address

69 E CLAPIER ST
PHILADELPHIA PA
19144-5932
US

V. Phone/Fax

Practice location:
  • Phone: 215-240-0445
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPN279988
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAG03250008
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: