Healthcare Provider Details

I. General information

NPI: 1487566782
Provider Name (Legal Business Name): FAERY MEDICAL, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2026
Last Update Date: 09/21/2026
Certification Date: 09/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1171 KING MILL RD
MCDONOUGH GA
30252-6927
US

IV. Provider business mailing address

1171 KING MILL RD
MCDONOUGH GA
30252-6927
US

V. Phone/Fax

Practice location:
  • Phone: 470-615-9709
  • Fax: 470-743-1075
Mailing address:
  • Phone: 470-615-9709
  • Fax: 470-743-1075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MELISSA ROTELLA
Title or Position: OWNER, PROVIDER
Credential: NP
Phone: 470-615-9709