Healthcare Provider Details

I. General information

NPI: 1417901315
Provider Name (Legal Business Name): TIFFANY ROSHEA PATTERSON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 12/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 COMMERCE BLVD SUITE 21
ANNISTON AL
36207-9451
US

IV. Provider business mailing address

1400 COMMERCE BLVD SUITE 21
ANNISTON AL
36207-9451
US

V. Phone/Fax

Practice location:
  • Phone: 256-831-3058
  • Fax: 256-835-8681
Mailing address:
  • Phone: 256-831-3058
  • Fax: 256-835-8681

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-148589
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1533
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: