Basic Information
Provider Information | |||||||||
NPI: | 1891362166 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TINNEY | ||||||||
FirstName: | AMBER | ||||||||
MiddleName: | KAY | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | C-AA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7060 NOVA DR APT 107 | ||||||||
Address2: |   | ||||||||
City: | DAVIE | ||||||||
State: | FL | ||||||||
PostalCode: | 333177174 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9125364228 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3476 S UNIVERSITY DR | ||||||||
Address2: |   | ||||||||
City: | DAVIE | ||||||||
State: | FL | ||||||||
PostalCode: | 333282000 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9544754400 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/07/2021 | ||||||||
LastUpdateDate: | 08/22/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/22/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 367H00000X | 2021034807 | MO | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |   |
No ID Information.