1003389875 NPI number — DR. TIFFANY KAYLA AUTRY DNP FNP MEP-C

Table of content: DR. TIFFANY KAYLA AUTRY DNP FNP MEP-C (NPI 1003389875)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003389875 NPI number — DR. TIFFANY KAYLA AUTRY DNP FNP MEP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AUTRY
Provider First Name:
TIFFANY
Provider Middle Name:
KAYLA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DNP FNP MEP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003389875
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/30/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 871
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS CRUCES
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88004-0871
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
409-719-8846
Provider Business Mailing Address Fax Number:
575-888-2273

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1005 S TELSHOR BLVD STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAS CRUCES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88011-4879
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-262-7546
Provider Business Practice Location Address Fax Number:
575-888-2273
Provider Enumeration Date:
01/04/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207N00000X , with the licence number:  54435 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 31106285 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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