Provider Demographics
NPI:1679171078
Name:GOUGEON, TIFFANY KRISTINE (RN)
Entity type:Individual
Prefix:MISS
First Name:TIFFANY
Middle Name:KRISTINE
Last Name:GOUGEON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1655 KEWALO ST APT E
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96822-3124
Mailing Address - Country:US
Mailing Address - Phone:413-695-5157
Mailing Address - Fax:
Practice Address - Street 1:56-660 KAMEHAMEHA HWY
Practice Address - Street 2:
Practice Address - City:KAHUKU
Practice Address - State:HI
Practice Address - Zip Code:96731-2210
Practice Address - Country:US
Practice Address - Phone:808-293-7555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-16
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI84703163WP0807X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0807XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Child & Adolescent