Provider Demographics
NPI:1740056845
Name:ROSELL, TIFFANY (LDO)
Entity type:Individual
Prefix:MRS
First Name:TIFFANY
Middle Name:
Last Name:ROSELL
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 1:635 EMERALD PKWY
Mailing Address - Street 2:
Mailing Address - City:SUGAR HILL
Mailing Address - State:GA
Mailing Address - Zip Code:30518-5668
Mailing Address - Country:US
Mailing Address - Phone:770-778-4506
Mailing Address - Fax:
Practice Address - Street 1:245 PEACHTREE INDUSTRIAL BLVD STE 103
Practice Address - Street 2:
Practice Address - City:SUGAR HILL
Practice Address - State:GA
Practice Address - Zip Code:30518-9126
Practice Address - Country:US
Practice Address - Phone:770-778-4506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALDO002788156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician