Healthcare Provider Details

I. General information

NPI: 1588309496
Provider Name (Legal Business Name): TIFFANY ELIZABETH HLADOVCAK NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2022
Last Update Date: 07/14/2022
Certification Date: 07/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5425 GARDEN LN
STEVENS POINT WI
54482-9377
US

IV. Provider business mailing address

5425 GARDEN LN
STEVENS POINT WI
54482-9377
US

V. Phone/Fax

Practice location:
  • Phone: 715-370-3534
  • Fax:
Mailing address:
  • Phone: 715-370-3534
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number226834-30
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number13026-33
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: