Basic Information
| Provider Information | |||||||||
| NPI: | 1457758419 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BLEASE | ||||||||
| FirstName: | AMBER | ||||||||
| MiddleName: | BROOKE | ||||||||
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| Credential: | NP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3233 | ||||||||
| Address2: | |||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 317763233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2295029788 | ||||||||
| FaxNumber: | 2298902166 | ||||||||
| Practice Location | |||||||||
| Address1: | 4 LIVE OAK CT | ||||||||
| Address2: | |||||||||
| City: | MOULTRIE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 31768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2295029788 | ||||||||
| FaxNumber: | 2298902166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2014 | ||||||||
| LastUpdateDate: | 11/04/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN213604 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | RN213604 | 01 | GA | GA LICENSE | OTHER |