Provider Demographics
NPI:1043509300
Name:AMBROSE, ELIZABETH MARIE
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARIE
Last Name:AMBROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:BETSY
Other - Middle Name:
Other - Last Name:AMBROSE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ARNP, FNP
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-312-3456
Mailing Address - Fax:321-951-7408
Practice Address - Street 1:1223 GATEWAY DRIVIE
Practice Address - Street 2:SUITE 1C
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-2607
Practice Address - Country:US
Practice Address - Phone:321-312-3456
Practice Address - Fax:321-676-9196
Is Sole Proprietor?:No
Enumeration Date:2011-04-06
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9217891363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLARNP9217891OtherFLORIDA LICENSE
FLEW744XOtherMEDICARE
CAW1514Medicare PIN
CA21419OtherNP LICENSE NUMBER
CA808147OtherRN LICENSE NUMBER
FLARNP9217891OtherFLORIDA LICENSE