Healthcare Provider Details

I. General information

NPI: 1679122501
Provider Name (Legal Business Name): BAMBI IVEY ALLEN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/04/2019
Last Update Date: 09/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

817 GRIFFIN AVE
EASTMAN GA
31023-6718
US

IV. Provider business mailing address

817 GRIFFIN AVE
EASTMAN GA
31023-6718
US

V. Phone/Fax

Practice location:
  • Phone: 478-374-1801
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN190630
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN190630
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: