Healthcare Provider Details

I. General information

NPI: 1922291004
Provider Name (Legal Business Name): REBECCA CARROS AMBROSE CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2007
Last Update Date: 11/18/2022
Certification Date: 11/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1279 HIGHWAY 54 W STE 100
FAYETTEVILLE GA
30214-4551
US

IV. Provider business mailing address

702 CANTON ROAD
MARIETTA GA
30060
US

V. Phone/Fax

Practice location:
  • Phone: 770-719-5710
  • Fax:
Mailing address:
  • Phone: 770-428-4486
  • Fax: 770-425-6008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN112110
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberRN112110
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: