Provider Demographics
NPI:1972245256
Name:DINEEN, TIFFANY DIANNE (AGNP-C)
Entity type:Individual
Prefix:MS
First Name:TIFFANY
Middle Name:DIANNE
Last Name:DINEEN
Suffix:
Gender:F
Credentials:AGNP-C
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 1:300 SINGLETON RIDGE RD
Mailing Address - Street 2:ATTN PNS CREDENTIALING
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526-9142
Mailing Address - Country:US
Mailing Address - Phone:843-234-6946
Mailing Address - Fax:
Practice Address - Street 1:251 UNIVERSITY BLVD
Practice Address - Street 2:STE B
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-8834
Practice Address - Country:US
Practice Address - Phone:843-347-1012
Practice Address - Fax:843-347-1218
Is Sole Proprietor?:No
Enumeration Date:2022-04-08
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25803363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology