Provider Demographics
NPI:1174115182
Name:KINNISON, TIFFANY M (APRN)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:M
Last Name:KINNISON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6650 W 110TH ST STE 220A
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1501
Mailing Address - Country:US
Mailing Address - Phone:913-549-3884
Mailing Address - Fax:913-273-3343
Practice Address - Street 1:634 SW MULVANE ST STE 405
Practice Address - Street 2:
Practice Address - City:TOPEKA
Practice Address - State:KS
Practice Address - Zip Code:66606-1678
Practice Address - Country:US
Practice Address - Phone:785-295-8470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-10
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2021003528364SA2200X
KS79985364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS30004752220001Medicaid