Basic Information
| Provider Information | |||||||||
| NPI: | 1174680177 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAHEK | ||||||||
| FirstName: | AMBER | ||||||||
| MiddleName: | D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 95 COLLIER ROAD | ||||||||
| Address2: | SUITE 5015 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046052800 | ||||||||
| FaxNumber: | 4043515983 | ||||||||
| Practice Location | |||||||||
| Address1: | 95 COLLIER ROAD | ||||||||
| Address2: | SUITE 5015 | ||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 30309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4046052800 | ||||||||
| FaxNumber: | 4043515983 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2007 | ||||||||
| LastUpdateDate: | 01/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN133358 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 060912445C, D | 05 | GA | MEDICAID |