Provider Demographics
NPI:1700459690
Name:BOELK, TIFFANY MARIE (APNP)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MARIE
Last Name:BOELK
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:MARIE
Other - Last Name:PICCHIOTTINO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:N3087 HICKORY RD
Mailing Address - Street 2:
Mailing Address - City:BYRON
Mailing Address - State:WI
Mailing Address - Zip Code:53006-1126
Mailing Address - Country:US
Mailing Address - Phone:920-517-2207
Mailing Address - Fax:
Practice Address - Street 1:420 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4560
Practice Address - Country:US
Practice Address - Phone:920-923-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-20
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10905-33363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily