Healthcare Provider Details

I. General information

NPI: 1124672076
Provider Name (Legal Business Name): TIFFANY L OGDEN LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2019
Last Update Date: 07/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

192 MASON AVE
ROCHESTER NY
14626-3355
US

IV. Provider business mailing address

192 MASON AVE
ROCHESTER NY
14626-3355
US

V. Phone/Fax

Practice location:
  • Phone: 585-802-2219
  • Fax:
Mailing address:
  • Phone: 585-802-2219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number321563
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: