Provider Demographics
NPI:1003169095
Name:AMBROSE, NICOLE LEE
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:LEE
Last Name:AMBROSE
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 1:350 RICHMOND TER APT 3C
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10301-1518
Mailing Address - Country:US
Mailing Address - Phone:917-974-2198
Mailing Address - Fax:
Practice Address - Street 1:1000 SOUTH AVENUE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-3409
Practice Address - Country:US
Practice Address - Phone:718-477-0961
Practice Address - Fax:718-761-1643
Is Sole Proprietor?:No
Enumeration Date:2012-10-16
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021832235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist