1972245256 NPI number — MS. TIFFANY DIANNE DINEEN AGNP-C

Table of content: MS. TIFFANY DIANNE DINEEN AGNP-C (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 AGNP-C

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:
AGNP-C
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:
08/29/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 SINGLETON RIDGE RD
Provider Second Line Business Mailing Address:
ATTN PNS CREDENTIALING
Provider Business Mailing Address City Name:
CONWAY
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29526-9142
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
843-234-6946
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
251 UNIVERSITY BLVD
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
CONWAY
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29526-8834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
843-347-1012
Provider Business Practice Location Address Fax Number:
843-347-1218
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: 363LG0600X , 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)





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