Healthcare Provider Details

I. General information

NPI: 1144939778
Provider Name (Legal Business Name): TIFFANY CAPPS BSN, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2022
Last Update Date: 11/22/2022
Certification Date: 11/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 S. WATER TOWER PL
MT. VERNON IL
62864
US

IV. Provider business mailing address

102 N DOGWOOD ST
BELLE RIVE IL
62810-1269
US

V. Phone/Fax

Practice location:
  • Phone: 618-246-2910
  • Fax: 618-242-8240
Mailing address:
  • Phone: 618-237-8433
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041319773
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: