Provider Demographics
NPI:1811792708
Name:MALLOY, TIFFANY
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:MALLOY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 HALAH CIR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-5241
Mailing Address - Country:US
Mailing Address - Phone:917-500-9330
Mailing Address - Fax:
Practice Address - Street 1:5 CONCOURSE PKWY STE 3000
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-7106
Practice Address - Country:US
Practice Address - Phone:917-500-9330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-15
Last Update Date:2025-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier