Healthcare Provider Details

I. General information

NPI: 1316639537
Provider Name (Legal Business Name): TIFFANY RENEE JOHNSON-BEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2023
Last Update Date: 05/25/2023
Certification Date: 05/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 BLOOMINGTON RD
CHAMPAIGN IL
61820-2101
US

IV. Provider business mailing address

PO BOX 2815
SPRINGFIELD IL
62708-2815
US

V. Phone/Fax

Practice location:
  • Phone: 217-356-1558
  • Fax:
Mailing address:
  • Phone: 217-306-8540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209027291
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: