Healthcare Provider Details

I. General information

NPI: 1962333849
Provider Name (Legal Business Name): TIFFANY DIAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2026
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7140 DEER CANYON AVE NE
ALBUQUERQUE NM
87113-2274
US

IV. Provider business mailing address

7140 DEER CANYON AVE NE
ALBUQUERQUE NM
87113-2274
US

V. Phone/Fax

Practice location:
  • Phone: 505-300-6135
  • Fax:
Mailing address:
  • Phone: 505-300-6135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberL17901
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: