Healthcare Provider Details

I. General information

NPI: 1093354458
Provider Name (Legal Business Name): AMBER LANAE BUSBY RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMBER LANAE BLACKWELL RN

II. Dates (important events)

Enumeration Date: 01/03/2020
Last Update Date: 02/12/2021
Certification Date: 02/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 HIGHWAY 78 E
JASPER AL
35501-4036
US

IV. Provider business mailing address

1861 TOMMY ROBINSON RD
JASPER AL
35504-6644
US

V. Phone/Fax

Practice location:
  • Phone: 205-512-1058
  • Fax:
Mailing address:
  • Phone: 205-275-5554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1-129220
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-129220
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: