Provider Demographics
NPI:1417901315
Name:PATTERSON, TIFFANY ROSHEA (RD)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:ROSHEA
Last Name:PATTERSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 COMMERCE BLVD
Mailing Address - Street 2:SUITE 21
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36207-9451
Mailing Address - Country:US
Mailing Address - Phone:256-831-3058
Mailing Address - Fax:256-835-8681
Practice Address - Street 1:1400 COMMERCE BLVD
Practice Address - Street 2:SUITE 21
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36207-9451
Practice Address - Country:US
Practice Address - Phone:256-831-3058
Practice Address - Fax:256-835-8681
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-148589363LF0000X
AL1533133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51531936OtherBLUE CROSS BLUE SHIELD
AL51531936OtherBLUE CROSS BLUE SHIELD
AL051554659Medicare ID - Type UnspecifiedMEDCARE PROVIDER