Provider Demographics
NPI:1336490606
Name:AMBROISE-JEAN, KERLANDE (RN)
Entity Type:Individual
Prefix:MRS
First Name:KERLANDE
Middle Name:
Last Name:AMBROISE-JEAN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 WAYMAN RD
Mailing Address - Street 2:
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28115
Mailing Address - Country:US
Mailing Address - Phone:704-204-4334
Mailing Address - Fax:
Practice Address - Street 1:116 WAYMAN RD
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28115
Practice Address - Country:US
Practice Address - Phone:704-204-4334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-27
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC219387163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCLANDE4634Medicaid