Provider Demographics
NPI:1356425482
Name:PATRICK, TIFFANY (CRNA)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:PATRICK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1310
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:KY
Mailing Address - Zip Code:40456-1310
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:145 NEWCOMB AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:KY
Practice Address - Zip Code:40456
Practice Address - Country:US
Practice Address - Phone:606-256-2195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3003382367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3003382OtherNURSE ANESTHETISTS