Healthcare Provider Details

I. General information

NPI: 1255115838
Provider Name (Legal Business Name): TIFFANI HENN APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2023
Last Update Date: 04/14/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 S ROUTE 31
CRYSTAL LAKE IL
60014-8190
US

IV. Provider business mailing address

29624 NETWORK PL
CHICAGO IL
60673-1296
US

V. Phone/Fax

Practice location:
  • Phone: 779-220-5500
  • Fax:
Mailing address:
  • Phone: 608-756-6278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.027821
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: