Healthcare Provider Details

I. General information

NPI: 1407094402
Provider Name (Legal Business Name): AMBER LEE PTAK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/28/2009
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 CHATTANOOGA AVE STE 1
DALTON GA
30720-2672
US

IV. Provider business mailing address

2607 W HILLVIEW DR
DALTON GA
30721-8120
US

V. Phone/Fax

Practice location:
  • Phone: 706-876-2130
  • Fax:
Mailing address:
  • Phone: 706-280-2861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN328617
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: