Healthcare Provider Details

I. General information

NPI: 1154036341
Provider Name (Legal Business Name): SARAH BRICENO FAMBROUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2023
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 OCILLA RD
DOUGLAS GA
31533-2262
US

IV. Provider business mailing address

1101 OCILLA RD
DOUGLAS GA
31533-2262
US

V. Phone/Fax

Practice location:
  • Phone: 912-384-1900
  • Fax:
Mailing address:
  • Phone: 912-384-1900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN259000
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: