Provider Demographics
NPI:1871992966
Name:THOMAS, TIFFANY DOMINIQUE (FNP-BC)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:DOMINIQUE
Last Name:THOMAS
Suffix:
Gender:F
Credentials:FNP-BC
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 916
Mailing Address - Street 2:
Mailing Address - City:HOMEWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60430-0916
Mailing Address - Country:US
Mailing Address - Phone:708-979-0728
Mailing Address - Fax:
Practice Address - Street 1:1217 US HIGHWAY 41
Practice Address - Street 2:
Practice Address - City:SCHERERVILLE
Practice Address - State:IN
Practice Address - Zip Code:46375-1311
Practice Address - Country:US
Practice Address - Phone:219-765-6545
Practice Address - Fax:219-227-8920
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-14
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209012017363LF0000X
IN71005138A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily