Basic Information
| Provider Information | |||||||||
| NPI: | 1760849343 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRAMBLIN | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 802 KENYON RD STE A | ||||||||
| Address2: | |||||||||
| City: | FORT DODGE | ||||||||
| State: | IA | ||||||||
| PostalCode: | 505015740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5155748484 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1000 10TH AVE | ||||||||
| Address2: | |||||||||
| City: | ACKLEY | ||||||||
| State: | IA | ||||||||
| PostalCode: | 506011701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6418472625 | ||||||||
| FaxNumber: | 6418472509 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2016 | ||||||||
| LastUpdateDate: | 10/14/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | A115619 | IA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | A115819 | IA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1124396387 | 01 | IA | TRIMARK PHYSICIANS GROUP NPI | OTHER |