Healthcare Provider Details

I. General information

NPI: 1619831625
Provider Name (Legal Business Name): MRS. SURREA OGLESBY IVY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2025
Last Update Date: 12/13/2025
Certification Date: 12/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3300 HAMILTON MILL RD STE 102
BUFORD GA
30519-4004
US

IV. Provider business mailing address

3300 HAMILTON MILL RD STE 102
BUFORD GA
30519-4004
US

V. Phone/Fax

Practice location:
  • Phone: 770-615-2364
  • Fax: 770-615-2364
Mailing address:
  • Phone: 770-615-2364
  • Fax: 770-615-2364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: