Healthcare Provider Details

I. General information

NPI: 1649763889
Provider Name (Legal Business Name): TIFFANY R MALANAPHY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2018
Last Update Date: 02/17/2021
Certification Date: 02/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 MONTGOMERY ST
DECORAH IA
52101-2325
US

IV. Provider business mailing address

400 10TH ST E
WACONIA MN
55387-4552
US

V. Phone/Fax

Practice location:
  • Phone: 563-382-2911
  • Fax: 952-442-3620
Mailing address:
  • Phone: 952-442-9770
  • Fax: 952-442-3620

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number228022
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberD125341
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: