Basic Information
| Provider Information | |||||||||
| NPI: | 1992275671 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PICKARD | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | AMBER | ||||||||
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| Credential: | APRN, CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 523 NORTH 3RD STREET | ||||||||
| Address2: | |||||||||
| City: | BRAINERD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564013054 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4110 51ST AVE S | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581047776 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7013643100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2018 | ||||||||
| LastUpdateDate: | 11/09/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 38149 | ND | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.