Healthcare Provider Details

I. General information

NPI: 1477988095
Provider Name (Legal Business Name): TIFFANY NICHOLE RUSSAW APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: TIFFANY NICHOLE PAYNE APRN

II. Dates (important events)

Enumeration Date: 09/13/2013
Last Update Date: 10/28/2025
Certification Date: 10/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 CASINO CENTER BLVD
LAS VEGAS NV
89101
US

IV. Provider business mailing address

300 S 4TH ST STE 2110
LAS VEGAS NV
89101-6014
US

V. Phone/Fax

Practice location:
  • Phone: 702-671-5637
  • Fax: 702-366-0576
Mailing address:
  • Phone: 216-544-4565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN75931
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberAPRN001581
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: