Healthcare Provider Details

I. General information

NPI: 1033633706
Provider Name (Legal Business Name): TIFFANY ANNE BRACAMONTE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TIFFANY ANNE SMITH

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 E CHEROKEE ST
SPRINGFIELD MO
65804-2203
US

IV. Provider business mailing address

1235 E CHEROKEE ST
SPRINGFIELD MO
65804-2203
US

V. Phone/Fax

Practice location:
  • Phone: 417-820-2115
  • Fax:
Mailing address:
  • Phone: 417-820-2115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2017024895
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: