Provider Demographics
NPI:1093011249
Name:AMBROSE, STEPHANIE (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:AMBROSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2015 UPPERGATE DR
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30322-0001
Mailing Address - Country:US
Mailing Address - Phone:404-785-3373
Mailing Address - Fax:
Practice Address - Street 1:550 PEACHTREE ST NE
Practice Address - Street 2:SUITE 1135
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-2212
Practice Address - Country:US
Practice Address - Phone:404-727-9610
Practice Address - Fax:404-712-1540
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-07
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0116023541390200000X
GA75594207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program