Healthcare Provider Details

I. General information

NPI: 1235610932
Provider Name (Legal Business Name): BREE ELLESSE BLACKWELL AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2018
Last Update Date: 08/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

527 STEPHENSON AVE UNIT A-3
SAVANNAH GA
31405-5923
US

IV. Provider business mailing address

527 STEPHENSON AVE
SAVANNAH GA
31405-5923
US

V. Phone/Fax

Practice location:
  • Phone: 912-352-8530
  • Fax:
Mailing address:
  • Phone: 912-352-8530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberAUD004144
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: