Healthcare Provider Details

I. General information

NPI: 1568953651
Provider Name (Legal Business Name): TIFFANY RENEE BAGWELL APRN, NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 08/01/2025
Certification Date: 08/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 W MAIN ST
WAVERLY TN
37185-1510
US

IV. Provider business mailing address

209 W MAIN ST
WAVERLY TN
37185-1510
US

V. Phone/Fax

Practice location:
  • Phone: 931-209-7033
  • Fax:
Mailing address:
  • Phone: 931-209-7033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number24198
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberAPN0000024198
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: