Provider Demographics
NPI:1023072600
Name:RIDLEY-BROWN, SUNDRA VICTORIA (CRNA)
Entity type:Individual
Prefix:
First Name:SUNDRA
Middle Name:VICTORIA
Last Name:RIDLEY-BROWN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 OLD MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:POWDER SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30127-4313
Mailing Address - Country:US
Mailing Address - Phone:248-814-9972
Mailing Address - Fax:248-814-9973
Practice Address - Street 1:3193 HOWELL MILL RD NW STE 315
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-2100
Practice Address - Country:US
Practice Address - Phone:678-596-5560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704109816367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104300730Medicaid
MISR109816OtherBLUE CROSS OF MI
MISR109816OtherBLUE CROSS OF MI
MIN24360106Medicare ID - Type Unspecified