MEDICARE: MRS. TIFFANY NICOLE CRENSHAW FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	1087041	TX
2	363LF0000X	Family Nurse Practitioner	1087041	TX

General Provider Information

NPI Number	:	1194458877
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TIFFANY NICOLE CRENSHAW FNP-C

Provider Business Mailing Address
First Line	:	965 COUNTY ROAD 1040
Second Line	:
City	:	COOPER
State	:	TX
Zip	:	75432-8519
Country	:	US
Telephone Number	:	940-768-9839
Fax Number	:

Provider Business Practice Location Address
First Line	:	1339 S BROADWAY ST
Second Line	:
City	:	SULPHUR SPRINGS
State	:	TX
Zip	:	75482-4895
Country	:	US
Telephone Number	:	903-951-1001
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/08/2022
Last Update Date	:	07/02/2024

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