Basic Information
| Provider Information | |||||||||
| NPI: | 1194336339 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRACKUS | ||||||||
| FirstName: | TIFFANY | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 E 5TH ST | ||||||||
| Address2: | |||||||||
| City: | COQUILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974231755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413963111 | ||||||||
| FaxNumber: | 5419365891 | ||||||||
| Practice Location | |||||||||
| Address1: | 790 E 5TH ST | ||||||||
| Address2: | |||||||||
| City: | COQUILLE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974231755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413963111 | ||||||||
| FaxNumber: | 5413965891 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2020 | ||||||||
| LastUpdateDate: | 11/03/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/03/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | TEMP65467 | ID | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 202009819NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.