Healthcare Provider Details

I. General information

NPI: 1972992493
Provider Name (Legal Business Name): AMBRA JORDAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2015
Last Update Date: 01/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3171 MAE AVE NE
BROOKHAVEN GA
30319-2323
US

IV. Provider business mailing address

3171 MAE
ATLANTA GA
30319
US

V. Phone/Fax

Practice location:
  • Phone: 404-606-0084
  • Fax:
Mailing address:
  • Phone: 404-606-0084
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN199382
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: