Healthcare Provider Details

I. General information

NPI: 1093054975
Provider Name (Legal Business Name): TIFFANY NICHOLSON NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2013
Last Update Date: 08/02/2021
Certification Date: 08/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JOHN JAMES AUDUBON PKWY STE 200
BUFFALO NY
14228-1145
US

IV. Provider business mailing address

108 ALDINE ST
ROCHESTER NY
14619-1204
US

V. Phone/Fax

Practice location:
  • Phone: 716-204-4500
  • Fax: 585-672-2527
Mailing address:
  • Phone: 585-208-7771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number605019
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number308982
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: