Provider Demographics
NPI:1700308509
Name:BOULANGER, TIFFANY LEE (AGACNP)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LEE
Last Name:BOULANGER
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7400 ABERCORN STREET
Mailing Address - Street 2:STE 704 BOX 104
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31406-2454
Mailing Address - Country:US
Mailing Address - Phone:912-232-9700
Mailing Address - Fax:912-748-0270
Practice Address - Street 1:400 TOWER RD NE STE 200
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-9412
Practice Address - Country:US
Practice Address - Phone:770-422-1372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-13
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA236517363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care