Provider Demographics
NPI:1093396186
Name:BEASLEY, TIFFANY MARIA (LDO)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:MARIA
Last Name:BEASLEY
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4917 DIXIE HWY STE H
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40216-2565
Mailing Address - Country:US
Mailing Address - Phone:502-447-2020
Mailing Address - Fax:
Practice Address - Street 1:4917 DIXIE HWY STE H
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-2565
Practice Address - Country:US
Practice Address - Phone:502-447-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-20
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY111351156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician