Healthcare Provider Details

I. General information

NPI: 1568990927
Provider Name (Legal Business Name): TIFFANY MARIE CONNER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2017
Last Update Date: 11/03/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13045 FALCON DR STE 100
BAXTER MN
56425-4201
US

IV. Provider business mailing address

13045 FALCON DR STE 100
BAXTER MN
56425-4201
US

V. Phone/Fax

Practice location:
  • Phone: 218-829-9307
  • Fax:
Mailing address:
  • Phone: 218-829-9307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number2017-039-A
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number3703
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: