1922643089 NPI number — TIFFANY WICKERT

Table of content: TIFFANY WICKERT (NPI 1922643089)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922643089 NPI number — TIFFANY WICKERT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WICKERT
Provider First Name:
TIFFANY
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
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:
1922643089
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19 DARTMOUTH DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAZLET
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07730-2322
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
347-552-2371
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
67A MOUNTAIN BLVD EXT.
Provider Second Line Business Practice Location Address:
1ST FLOOR, UNIT B
Provider Business Practice Location Address City Name:
WARREN
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
07059-5626
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
908-873-6337
Provider Business Practice Location Address Fax Number:
908-332-5668
Provider Enumeration Date:
11/13/2019

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: 235Z00000X , with the licence number:  032797 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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