Healthcare Provider Details

I. General information

NPI: 1225565948
Provider Name (Legal Business Name): TIFFANY NELSON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 NORTH MAIN STREET
GIDEON MO
63848
US

IV. Provider business mailing address

PO BOX 660
BROOKLAND AR
72417-0660
US

V. Phone/Fax

Practice location:
  • Phone: 573-448-3800
  • Fax:
Mailing address:
  • Phone: 870-489-8633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberR85700
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2017033835
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: