MEDICARE: TIFFANY LACK APRN, FNP-BC

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	363LF0000X	Family Nurse Practitioner	123569	AR

General Provider Information

NPI Number	:	1700431723
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIFFANY LACK APRN, FNP-BC

Provider Business Mailing Address
First Line	:	2001 CLUB MANOR DR STE S
Second Line	:
City	:	MAUMELLE
State	:	AR
Zip	:	72113-7417
Country	:	US
Telephone Number	:	501-734-8085
Fax Number	:	501-734-8088

Provider Business Practice Location Address
First Line	:	2001 CLUB MANOR DR STE S
Second Line	:
City	:	MAUMELLE
State	:	AR
Zip	:	72113-7417
Country	:	US
Telephone Number	:	501-734-8085
Fax Number	:	501-734-8085

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

Provider Enumeration Date	:	08/06/2019
Last Update Date	:	04/24/2024

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