Healthcare Provider Details

I. General information

NPI: 1093388068
Provider Name (Legal Business Name): AMY TIFFANY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2021
Last Update Date: 07/19/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

723 S LACLEDE STATION RD
SAINT LOUIS MO
63119-4911
US

IV. Provider business mailing address

723 S LACLEDE STATION RD
SAINT LOUIS MO
63119-4911
US

V. Phone/Fax

Practice location:
  • Phone: 314-446-2514
  • Fax:
Mailing address:
  • Phone: 314-446-2514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1600X
TaxonomyContinuing Education/Staff Development Registered Nurse
License Number2009019798
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: