Basic Information
Provider Information | |||||||||
NPI: | 1255763488 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WALL | ||||||||
FirstName: | TIFFANY | ||||||||
MiddleName: | GARRIS | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GARRIS | ||||||||
OtherFirstName: | TIFFANY | ||||||||
OtherMiddleName: | K | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | NP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 9228 MEDICAL PLAZA DR | ||||||||
Address2: |   | ||||||||
City: | CHARLESTON | ||||||||
State: | SC | ||||||||
PostalCode: | 294069125 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8435745693 | ||||||||
FaxNumber: | 8437644512 | ||||||||
Practice Location | |||||||||
Address1: | 9228 MEDICAL PLAZA DR | ||||||||
Address2: |   | ||||||||
City: | CHARLESTON | ||||||||
State: | SC | ||||||||
PostalCode: | 294069125 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8435745693 | ||||||||
FaxNumber: | 8437644512 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/30/2013 | ||||||||
LastUpdateDate: | 01/18/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/18/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 18412 | SC | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 18412 | SC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
No ID Information.