Basic Information
| Provider Information | |||||||||
| NPI: | 1962094565 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIAZ | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | RENE | ||||||||
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| Credential: | APRN-CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 S 70TH ST | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729035197 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 7217 CAMERON PARK DR | ||||||||
| Address2: | |||||||||
| City: | FORT SMITH | ||||||||
| State: | AR | ||||||||
| PostalCode: | 729036167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4798316007 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2021 | ||||||||
| LastUpdateDate: | 02/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 214718 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.