1972245256 NPI number — MS. TIFFANY DIANNE DINEEN APRN

Table of content: MS. TIFFANY DIANNE DINEEN APRN (NPI 1972245256)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972245256 NPI number — MS. TIFFANY DIANNE DINEEN APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DINEEN
Provider First Name:
TIFFANY
Provider Middle Name:
DIANNE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FOGLE
Provider Other First Name:
TIFFANY
Provider Other Middle Name:
DIANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1972245256
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
170 VILLAGE CENTR BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MYRTLE BEACH
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29579
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-449-5848
Provider Business Mailing Address Fax Number:
843-692-0908

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
170 VILLAGE CENTR BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MYRTLE BEACH
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29579
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-449-5848
Provider Business Practice Location Address Fax Number:
843-692-0908
Provider Enumeration Date:
04/08/2022

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  25803 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP2300X , with the licence number: 25803 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)