Healthcare Provider Details

I. General information

NPI: 1447495890
Provider Name (Legal Business Name): TIFFANY BROOKE BRATINA CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2008
Last Update Date: 11/22/2023
Certification Date: 11/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HAWTHORNE LN
CHARLOTTE NC
28204-2515
US

IV. Provider business mailing address

200 HAWTHORNE LN
CHARLOTTE NC
28204-2515
US

V. Phone/Fax

Practice location:
  • Phone: 704-384-4239
  • Fax: 704-384-5836
Mailing address:
  • Phone: 704-384-4239
  • Fax: 704-384-5836

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number227861
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: