Provider Demographics
NPI:1255763488
Name:WALL, TIFFANY GARRIS (NP-C)
Entity type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:GARRIS
Last Name:WALL
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:K
Other - Last Name:GARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:9228 MEDICAL PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9125
Mailing Address - Country:US
Mailing Address - Phone:843-574-5693
Mailing Address - Fax:843-764-4512
Practice Address - Street 1:9228 MEDICAL PLAZA DR
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9125
Practice Address - Country:US
Practice Address - Phone:843-574-5693
Practice Address - Fax:843-764-4512
Is Sole Proprietor?:No
Enumeration Date:2013-07-30
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18412363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily