Healthcare Provider Details

I. General information

NPI: 1679019301
Provider Name (Legal Business Name): TIFFANY J PORTER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TIFFANY NITTI FNP

II. Dates (important events)

Enumeration Date: 01/19/2017
Last Update Date: 06/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12200 WESTERN AVE
BLUE ISLAND IL
60406-1398
US

IV. Provider business mailing address

1301 FOX MEADOW CT
ST CHARLES IL
60174-1670
US

V. Phone/Fax

Practice location:
  • Phone: 630-581-5372
  • Fax:
Mailing address:
  • Phone: 630-915-8693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SF0001X
TaxonomyFamily Health Clinical Nurse Specialist
License Number209015112
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209015112
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: