Provider Demographics
NPI:1366799041
Name:AMBROSIA, HEATHER NICOLE (OD)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:NICOLE
Last Name:AMBROSIA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:NICOLE
Other - Last Name:RODEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:1000 CORPORATE CENTER DR STE 100
Mailing Address - Street 2:
Mailing Address - City:MORROW
Mailing Address - State:GA
Mailing Address - Zip Code:30260-4106
Mailing Address - Country:US
Mailing Address - Phone:770-968-8888
Mailing Address - Fax:770-960-2473
Practice Address - Street 1:1000 CORPORATE CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:GA
Practice Address - Zip Code:30260-4106
Practice Address - Country:US
Practice Address - Phone:770-968-8888
Practice Address - Fax:770-960-2473
Is Sole Proprietor?:No
Enumeration Date:2012-08-13
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOPT 002719152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003128849AMedicaid
20241I2658Medicare PIN