=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497072912
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIFFANY LEIGH SCHULTHEIS RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2010
-----------------------------------------------------
Last Update Date | 04/23/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4507 ASHLEY LN
-----------------------------------------------------
City | FULTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62244-1529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-458-7398
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4507 ASHLEY LN
-----------------------------------------------------
City | FULTS
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62244-1529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-458-7398
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | 041356623
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WC0200X
-----------------------------------------------------
Taxonomy Name | Critical Care Medicine Registered Nurse
-----------------------------------------------------
License Number | 2005008604
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------