Basic Information
| Provider Information | |||||||||
| NPI: | 1598832396 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DESIMONE | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | SIMPSON | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SIMPSON | ||||||||
| OtherFirstName: | TIFFANY | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ARNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9113 LEESGATE RD | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402225003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024261621 | ||||||||
| FaxNumber: | 5024267906 | ||||||||
| Practice Location | |||||||||
| Address1: | 9113 LEESGATE RD | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402225003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024261621 | ||||||||
| FaxNumber: | 5024267906 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/29/2006 | ||||||||
| LastUpdateDate: | 05/06/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 5060P | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207K00000X | 5060P | KY | N | Allopathic & Osteopathic Physicians | Allergy & Immunology |
ID Information
| ID | Type | State | Issuer | Description | 50015028 | 01 | KY | PASSPORT | OTHER | 3005060P | 01 | KY | APRN LICENSE | OTHER | 200853030 | 05 | IN | MEDICAID | 000000501202 | 01 | KY | ANTHEM | OTHER | 78017936 | 05 | KY | MEDICAID |