Healthcare Provider Details

I. General information

NPI: 1932144557
Provider Name (Legal Business Name): JENNIFER HUMPHREYS PAAA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2006
Last Update Date: 04/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 MEDICAL CENTER BLVD
LAWRENCEVILLE GA
30046-0000
US

IV. Provider business mailing address

PO BOX 551420
FORT LAUDERDALE FL
33355-1420
US

V. Phone/Fax

Practice location:
  • Phone: 770-277-3056
  • Fax: 855-204-5244
Mailing address:
  • Phone: 800-243-3839
  • Fax: 954-839-2569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License Number004172
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: