Healthcare Provider Details

I. General information

NPI: 1285338491
Provider Name (Legal Business Name): TIFFANY MARIAM CUELLO SIEGEL FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2023
Last Update Date: 07/29/2023
Certification Date: 07/29/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 US HIGHWAY 46
LEDGEWOOD NJ
07852-9738
US

IV. Provider business mailing address

89 CONNELLY AVE
BUDD LAKE NJ
07828-2528
US

V. Phone/Fax

Practice location:
  • Phone: 866-389-2727
  • Fax:
Mailing address:
  • Phone: 201-737-8622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ01366000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: