Basic Information
| Provider Information | |||||||||
| NPI: | 1366001752 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOWLER | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CNM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 SINGLETON RIDGE RD | ||||||||
| Address2: | ATTENTION PNS CREDENTIALING | ||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295269142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8432346946 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2376 CYPRESS CIR STE 200 | ||||||||
| Address2: | |||||||||
| City: | CONWAY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295268994 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8433477216 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2019 | ||||||||
| LastUpdateDate: | 08/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | MW0265 | 05 | SC | MEDICAID |