Provider Demographics
NPI:1184960767
Name:VANCIL, TIFFANY LEIGH (CRNA)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:LEIGH
Last Name:VANCIL
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:LEIGH
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 3330
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84110-3330
Mailing Address - Country:US
Mailing Address - Phone:888-333-1095
Mailing Address - Fax:
Practice Address - Street 1:470 NE A ST
Practice Address - Street 2:
Practice Address - City:MADRAS
Practice Address - State:OR
Practice Address - Zip Code:97741-1844
Practice Address - Country:US
Practice Address - Phone:541-475-3882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-30
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60327805367500000X
OR201392745CRNA367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered