MEDICARE: TIFFANI PETERSEN NP

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	7453288-4405	UT

General Provider Information

NPI Number	:	1255968681
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANI PETERSEN NP

Provider Business Mailing Address
First Line	:	PO BOX 27128
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84127-0128
Country	:	US
Telephone Number	:	801-357-7525
Fax Number	:

Provider Business Practice Location Address
First Line	:	395 W COUGAR BLVD STE 601
Second Line	:
City	:	PROVO
State	:	UT
Zip	:	84604-3331
Country	:	US
Telephone Number	:	801-357-7525
Fax Number	:

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

Provider Enumeration Date	:	03/25/2020
Last Update Date	:	01/27/2026

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