Healthcare Provider Details

I. General information

NPI: 1174410062
Provider Name (Legal Business Name): TIFFANY MICHELLE KUYKENDALL- SHAFER NP STUDENT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TIFFANY MICHELLE KUYKENDALL-SHAFER NP STUDENT

II. Dates (important events)

Enumeration Date: 06/23/2025
Last Update Date: 06/23/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1061 HARMON AVE
FORT STEWART GA
31314-5641
US

IV. Provider business mailing address

1061 HARMON AVE
FORT STEWART GA
31314-5641
US

V. Phone/Fax

Practice location:
  • Phone: 571-802-0394
  • Fax:
Mailing address:
  • Phone: 571-802-0394
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN302774
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: