Provider Demographics
NPI:1902456536
Name:THOMPSON, TIFFANY NICOLE (FNP)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:NICOLE
Last Name:THOMPSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 BLINKA LN
Mailing Address - Street 2:
Mailing Address - City:PORT LAVACA
Mailing Address - State:TX
Mailing Address - Zip Code:77979-5662
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 BLINKA LN
Practice Address - Street 2:
Practice Address - City:PORT LAVACA
Practice Address - State:TX
Practice Address - Zip Code:77979-5662
Practice Address - Country:US
Practice Address - Phone:361-746-0034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-16
Last Update Date:2019-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP142673363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily