Provider Demographics
NPI:1932243136
Name:TRENT-JOHNNEY, AMBROZINE OPHELIA (PA-C)
Entity type:Individual
Prefix:
First Name:AMBROZINE
Middle Name:OPHELIA
Last Name:TRENT-JOHNNEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5910 HILLANDALE DR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LITHONIA
Mailing Address - State:GA
Mailing Address - Zip Code:30058-1884
Mailing Address - Country:US
Mailing Address - Phone:678-418-2120
Mailing Address - Fax:678-418-2936
Practice Address - Street 1:5910 HILLANDALE DR
Practice Address - Street 2:SUITE 301
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-1884
Practice Address - Country:US
Practice Address - Phone:678-418-2120
Practice Address - Fax:678-418-2936
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004798363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA004798OtherSTATE LICENSE