Healthcare Provider Details

I. General information

NPI: 1437447190
Provider Name (Legal Business Name): TIFFANY KAE PROFSKY NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2011
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 CHIPETA WAY
SALT LAKE CITY UT
84108-1287
US

IV. Provider business mailing address

295 CHIPETA WAY
SALT LAKE CITY UT
84108-1287
US

V. Phone/Fax

Practice location:
  • Phone: 801-587-7416
  • Fax:
Mailing address:
  • Phone: 801-587-7416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4731862-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: