Healthcare Provider Details

I. General information

NPI: 1538940887
Provider Name (Legal Business Name): TIFFANY SMAHA APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2023
Last Update Date: 04/01/2024
Certification Date: 04/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 ROXBURY RD
ROCKFORD IL
61107-5078
US

IV. Provider business mailing address

401 ROXBURY RD
ROCKFORD IL
61107-5078
US

V. Phone/Fax

Practice location:
  • Phone: 815-397-7340
  • Fax:
Mailing address:
  • Phone: 815-397-7340
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209028383
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: