Healthcare Provider Details

I. General information

NPI: 1720550106
Provider Name (Legal Business Name): TIFFANY J INTANO FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2018
Last Update Date: 12/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4755 OGLETOWN STANTON RD
NEWARK DE
19718-2200
US

IV. Provider business mailing address

23 RHODES MOUNTAIN DR
NORTH EAST MD
21901-3635
US

V. Phone/Fax

Practice location:
  • Phone: 302-733-1000
  • Fax:
Mailing address:
  • Phone: 210-865-9503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberLG-0001214
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: