Provider Demographics
NPI:1073533782
Name:BOWEN, TIFFANY ALLISON (NNP, PNP)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ALLISON
Last Name:BOWEN
Suffix:
Gender:F
Credentials:NNP, PNP
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:
Other - Last Name:WINGATE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NNP, PNP
Mailing Address - Street 1:321 E FIFTEENTH ST
Mailing Address - Street 2:
Mailing Address - City:YAZOO CITY
Mailing Address - State:MS
Mailing Address - Zip Code:39194-2631
Mailing Address - Country:US
Mailing Address - Phone:662-532-1543
Mailing Address - Fax:662-532-1544
Practice Address - Street 1:321 E FIFTEENTH ST
Practice Address - Street 2:
Practice Address - City:YAZOO CITY
Practice Address - State:MS
Practice Address - Zip Code:39194-2631
Practice Address - Country:US
Practice Address - Phone:662-532-1543
Practice Address - Fax:662-532-1544
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR855554363LN0000X, 363LN0005X, 363LP0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS001003099Medicaid