=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083265284
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KIDZ 1ST CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/27/2019
-----------------------------------------------------
Last Update Date | 05/31/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 321 E FIFTEENTH ST
-----------------------------------------------------
City | YAZOO CITY
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39194-2631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-532-1543
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 321 E FIFTEENTH ST
-----------------------------------------------------
City | YAZOO CITY
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39194-2631
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-532-1543
-----------------------------------------------------
Fax | 662-532-1544
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | TIFFANY ALLISON BOWEN
-----------------------------------------------------
Credential | CPNP-PC
-----------------------------------------------------
Telephone | 662-532-1543
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------