Healthcare Provider Details

I. General information

NPI: 1154188381
Provider Name (Legal Business Name): BRANDY JO ANN ROOFFENER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2024
Last Update Date: 03/04/2024
Certification Date: 03/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MEDICAL CENTER BLVD
LAWRENCEVILLE GA
30046-7694
US

IV. Provider business mailing address

1737 SAPLING CT
LAWRENCEVILLE GA
30043-8311
US

V. Phone/Fax

Practice location:
  • Phone: 205-522-7721
  • Fax:
Mailing address:
  • Phone: 205-522-7721
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number1-151418
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: