Healthcare Provider Details

I. General information

NPI: 1386918811
Provider Name (Legal Business Name): TIFFANY LANDA FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2012
Last Update Date: 12/05/2024
Certification Date: 12/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 E 11TH ST
LIBERAL KS
67901-2784
US

IV. Provider business mailing address

709 E 4TH ST
HUGOTON KS
67951-3203
US

V. Phone/Fax

Practice location:
  • Phone: 620-624-2565
  • Fax: 620-624-3016
Mailing address:
  • Phone: 719-859-4786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number76027
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: