Healthcare Provider Details

I. General information

NPI: 1417745951
Provider Name (Legal Business Name): TIFFANY BURRO
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2025
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1727 N OCEAN AVE
MEDFORD NY
11763-2649
US

IV. Provider business mailing address

44 W GREENTREE DR
MEDFORD NY
11763-1690
US

V. Phone/Fax

Practice location:
  • Phone: 631-804-0769
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number406368
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: