Provider Demographics
NPI:1972245256
Name:DINEEN, TIFFANY DIANNE (APRN)
Entity Type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:DIANNE
Last Name:DINEEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:DIANNE
Other - Last Name:FOGLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:170 VILLAGE CENTR BLVD
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579
Mailing Address - Country:US
Mailing Address - Phone:843-449-5848
Mailing Address - Fax:843-692-0908
Practice Address - Street 1:170 VILLAGE CENTR BLVD
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579
Practice Address - Country:US
Practice Address - Phone:843-449-5848
Practice Address - Fax:843-692-0908
Is Sole Proprietor?:No
Enumeration Date:2022-04-08
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25803363LA2200X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health