Provider Demographics
NPI:1255693016
Name:AMBROSE, DIANE
Entity Type:Individual
Prefix:
First Name:DIANE
Middle Name:
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 1:135 N ELM ST
Mailing Address - Street 2:
Mailing Address - City:N MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-2648
Mailing Address - Country:US
Mailing Address - Phone:516-541-2594
Mailing Address - Fax:516-795-7317
Practice Address - Street 1:135 N ELM ST
Practice Address - Street 2:
Practice Address - City:N MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-2648
Practice Address - Country:US
Practice Address - Phone:516-541-2594
Practice Address - Fax:516-795-7317
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-07
Last Update Date:2012-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist