Healthcare Provider Details

I. General information

NPI: 1063231900
Provider Name (Legal Business Name): TIFFANY HAWTHORNE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/08/2024
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 W CHAMBERS ST
MILWAUKEE WI
53210-1650
US

IV. Provider business mailing address

9025 S MARSHFIELD AVE
CHICAGO IL
60620-5546
US

V. Phone/Fax

Practice location:
  • Phone: 414-447-2000
  • Fax:
Mailing address:
  • Phone: 773-654-8112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number041478292
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number18818
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209.030813
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: