Provider Demographics
NPI:1871909242
Name:FLATEN, TIFFANY (MS, LN, CNS)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:FLATEN
Suffix:
Gender:F
Credentials:MS, LN, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4655 LANNON AVE NE
Mailing Address - Street 2:
Mailing Address - City:SAINT MICHAEL
Mailing Address - State:MN
Mailing Address - Zip Code:55376-4613
Mailing Address - Country:US
Mailing Address - Phone:763-300-4816
Mailing Address - Fax:
Practice Address - Street 1:9201 QUADAY AVE NE STE 205
Practice Address - Street 2:
Practice Address - City:OTSEGO
Practice Address - State:MN
Practice Address - Zip Code:55330-6604
Practice Address - Country:US
Practice Address - Phone:763-703-6962
Practice Address - Fax:651-222-9727
Is Sole Proprietor?:No
Enumeration Date:2014-07-07
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1871909242Medicaid