Basic Information
| Provider Information | |||||||||
| NPI: | 1386805034 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NUNNELLEY | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8620 N 22ND AVE | ||||||||
| Address2: | 200 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850214251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6026746506 | ||||||||
| FaxNumber: | 6026746512 | ||||||||
| Practice Location | |||||||||
| Address1: | 6036 N 19TH AVE | ||||||||
| Address2: | 505 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6028410721 | ||||||||
| FaxNumber: | 6028410729 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2008 | ||||||||
| LastUpdateDate: | 12/16/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4788 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 438727 | 05 | AZ | MEDICAID |