Healthcare Provider Details

I. General information

NPI: 1164064804
Provider Name (Legal Business Name): TIFFANY N ROGERS APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TIFFANY N PORTER

II. Dates (important events)

Enumeration Date: 10/15/2019
Last Update Date: 09/28/2022
Certification Date: 09/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2349 VILLAGE SQUARE PKWY STE 107
FLEMING ISLAND FL
32003-4319
US

IV. Provider business mailing address

5191 FIRST COAST TECH PKWY 3RD FLOOR
JACKSONVILLE FL
32224-0609
US

V. Phone/Fax

Practice location:
  • Phone: 904-223-3321
  • Fax: 904-223-2169
Mailing address:
  • Phone: 904-223-3321
  • Fax: 904-223-2169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11004264
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: