Provider Demographics
NPI:1861990780
Name:ROBERTS, TIFFANY TOMIYE (FNP-C)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:TOMIYE
Last Name:ROBERTS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 427
Mailing Address - Street 2:
Mailing Address - City:PACIFIC CITY
Mailing Address - State:OR
Mailing Address - Zip Code:97135-0427
Mailing Address - Country:US
Mailing Address - Phone:503-310-3582
Mailing Address - Fax:
Practice Address - Street 1:34980 LAHAINA LOOP RD
Practice Address - Street 2:
Practice Address - City:CLOVERDALE
Practice Address - State:OR
Practice Address - Zip Code:97112-9112
Practice Address - Country:US
Practice Address - Phone:503-310-3582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-25
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10004660363LF0000X
NC5010214363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1861990780Medicaid