Healthcare Provider Details

I. General information

NPI: 1871953075
Provider Name (Legal Business Name): TIFFANY DEGNAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2016
Last Update Date: 03/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4815 BURNING TREE RD
DULUTH MN
55811-3800
US

IV. Provider business mailing address

4815 BURNING TREE RD
DULUTH MN
55811-3800
US

V. Phone/Fax

Practice location:
  • Phone: 218-733-0707
  • Fax: 218-733-0717
Mailing address:
  • Phone: 218-733-0707
  • Fax: 218-733-0717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number225516-7
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number224473
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: