Provider Demographics
NPI:1285332288
Name:AMMONS, AMBER N (MT)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:N
Last Name:AMMONS
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 N BROAD ST
Mailing Address - Street 2:
Mailing Address - City:PORTERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30014-3351
Mailing Address - Country:US
Mailing Address - Phone:678-262-7386
Mailing Address - Fax:
Practice Address - Street 1:1343 BUSINESS CENTER DR SW
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094-6608
Practice Address - Country:US
Practice Address - Phone:678-262-7386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT012981225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist