Healthcare Provider Details

I. General information

NPI: 1386558195
Provider Name (Legal Business Name): TIFFANY ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1149 W 84TH ST
CHICAGO IL
60620-3106
US

IV. Provider business mailing address

4252 RESERVE WAY APT 2093
IRVING TX
75038-9074
US

V. Phone/Fax

Practice location:
  • Phone: 773-407-9586
  • Fax:
Mailing address:
  • Phone: 708-510-8455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number1071664
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: