Healthcare Provider Details

I. General information

NPI: 1316648900
Provider Name (Legal Business Name): TIFFANY WALTON-BOONE WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2023
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 E WYOMING AVE
PHILADELPHIA PA
19124-3808
US

IV. Provider business mailing address

5037 GREENE ST
PHILADELPHIA PA
19144-2969
US

V. Phone/Fax

Practice location:
  • Phone: 267-736-0153
  • Fax:
Mailing address:
  • Phone: 267-736-0153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberSP027161
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: