Provider Demographics
NPI:1659065472
Name:BUNCH, AMBER HOLLY
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:HOLLY
Last Name:BUNCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1484 LAKE CITY INDUSTRIAL CT
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:GA
Mailing Address - Zip Code:30260-3544
Mailing Address - Country:US
Mailing Address - Phone:470-491-2219
Mailing Address - Fax:
Practice Address - Street 1:1484 LAKE CITY INDUSTRIAL CT
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:GA
Practice Address - Zip Code:30260-3544
Practice Address - Country:US
Practice Address - Phone:470-491-2219
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-05
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA-13625-110122246RP1900X
171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy