Provider Demographics
NPI:1457758419
Name:BLEASE, AMBER BROOKE (NP-C)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:BROOKE
Last Name:BLEASE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3233
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-3233
Mailing Address - Country:US
Mailing Address - Phone:229-502-9788
Mailing Address - Fax:229-890-2166
Practice Address - Street 1:4 LIVE OAK CT
Practice Address - Street 2:
Practice Address - City:MOULTRIE
Practice Address - State:GA
Practice Address - Zip Code:31768
Practice Address - Country:US
Practice Address - Phone:229-502-9788
Practice Address - Fax:229-890-2166
Is Sole Proprietor?:No
Enumeration Date:2014-11-19
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN213604363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN213604OtherGA LICENSE