Healthcare Provider Details

I. General information

NPI: 1255711297
Provider Name (Legal Business Name): MRS. TIFFANY HOPE SHEPHERD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TIFFANY HOPE STEPHENS TYSON NP

II. Dates (important events)

Enumeration Date: 06/04/2015
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6507 NORTH KINGS HWY
MYRTLE BEACH SC
29572
US

IV. Provider business mailing address

6507 NORTH KINGS HWY DR NORMAN'S MYRTLE BEACH DIET & REGENERATIVE CENTER
MYRTLE BEACH SC
29572
US

V. Phone/Fax

Practice location:
  • Phone: 843-692-9494
  • Fax: 843-692-7474
Mailing address:
  • Phone: 843-692-9494
  • Fax: 843-692-7474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5007642
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number5007642
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN.19719
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: