Healthcare Provider Details

I. General information

NPI: 1114279700
Provider Name (Legal Business Name): TIFFANY RICHARDSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2012
Last Update Date: 05/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21120 WASHINGTON PKWY
FRANKFORT IL
60423-3112
US

IV. Provider business mailing address

8135 S ARTESIAN AVE
CHICAGO IL
60652-2838
US

V. Phone/Fax

Practice location:
  • Phone: 815-469-9750
  • Fax:
Mailing address:
  • Phone: 773-471-5461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209010386
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: