Provider Demographics
NPI:1366040693
Name:AMBROSE, KATHERINE LEE
Entity Type:Individual
Prefix:
First Name:KATHERINE
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 1:200 MCDANIEL AVE
Mailing Address - Street 2:
Mailing Address - City:PICKENS
Mailing Address - State:SC
Mailing Address - Zip Code:29671-2527
Mailing Address - Country:US
Mailing Address - Phone:864-898-5965
Mailing Address - Fax:
Practice Address - Street 1:200 MCDANIEL AVE
Practice Address - Street 2:
Practice Address - City:PICKENS
Practice Address - State:SC
Practice Address - Zip Code:29671-2527
Practice Address - Country:US
Practice Address - Phone:864-898-5965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2349882083P0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2083P0901XAllopathic & Osteopathic PhysiciansPreventive MedicinePublic Health & General Preventive Medicine