Healthcare Provider Details

I. General information

NPI: 1063230506
Provider Name (Legal Business Name): TIFFANY KATHLEEN WIECKOWSKI APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2024
Last Update Date: 05/03/2025
Certification Date: 05/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

653 W 8TH ST
JACKSONVILLE FL
32209-6511
US

IV. Provider business mailing address

PO BOX 44008
JACKSONVILLE FL
32231-4008
US

V. Phone/Fax

Practice location:
  • Phone: 904-383-1015
  • Fax:
Mailing address:
  • Phone: 904-383-1015
  • Fax: 904-244-8172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License NumberRN9516596
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License NumberAPRN11038005
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: