Healthcare Provider Details

I. General information

NPI: 1922556612
Provider Name (Legal Business Name): TIFFANY L BENNETT CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2016
Last Update Date: 09/02/2026
Certification Date: 01/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12502 WILLOWBROOK RD STE 380
CUMBERLAND MD
21502-6592
US

IV. Provider business mailing address

PO BOX 1671
CUMBERLAND MD
21501-1671
US

V. Phone/Fax

Practice location:
  • Phone: 240-964-8585
  • Fax: 240-964-8586
Mailing address:
  • Phone: 240-964-8585
  • Fax: 240-964-8586

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR163851
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR163851
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: