Basic Information
| Provider Information | |||||||||
| NPI: | 1811349194 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JOHNSON | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 375 SEDILLO RD | ||||||||
| Address2: | |||||||||
| City: | TIJERAS | ||||||||
| State: | NM | ||||||||
| PostalCode: | 870597336 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052202081 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2600 MARBLE AVE NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 87106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052722800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2016 | ||||||||
| LastUpdateDate: | 07/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | CNP02970 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.