Healthcare Provider Details

I. General information

NPI: 1265340731
Provider Name (Legal Business Name): TIFFANY VAN DYKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1639 BASELINE ST UNIT 123
CORNELIUS OR
97113-0816
US

IV. Provider business mailing address

PO BOX 123
CORNELIUS OR
97113-0123
US

V. Phone/Fax

Practice location:
  • Phone: 503-318-7936
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225500000X
TaxonomyRespiratory/Developmental/Rehabilitative Specialist/Technologist
License NumberCOS-NT-953813
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: