Healthcare Provider Details

I. General information

NPI: 1124490008
Provider Name (Legal Business Name): TIFFANY HERMAN DIESO AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2015
Last Update Date: 04/06/2021
Certification Date: 04/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 MEDICINE CIR
DURHAM NC
27710-0001
US

IV. Provider business mailing address

5213 S ALSTON AVE
DURHAM NC
27713-4430
US

V. Phone/Fax

Practice location:
  • Phone: 919-385-7941
  • Fax:
Mailing address:
  • Phone: 919-620-4855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number246947
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: