Provider Demographics
NPI:1366506081
Name:AMBROZ, COLLEEN
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:
Last Name:AMBROZ
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 1:301 2ND ST NE
Mailing Address - Street 2:
Mailing Address - City:NEW PRAGUE
Mailing Address - State:MN
Mailing Address - Zip Code:56071-1709
Mailing Address - Country:US
Mailing Address - Phone:952-758-4431
Mailing Address - Fax:
Practice Address - Street 1:301 2ND ST NE
Practice Address - Street 2:
Practice Address - City:NEW PRAGUE
Practice Address - State:MN
Practice Address - Zip Code:56071-1709
Practice Address - Country:US
Practice Address - Phone:952-758-4431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2021-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN01033011OtherPREFFEREDONE CLINIC NUMBE
MN6407367OtherMEDICA PROVIDER NUMBER
MNHP77101OtherHEALTH PARTNERS PROVIDER
MN515L6PEOtherMN BLUE CROSS PROVIDER NU
MN430027000Medicaid
MN650001747Medicare ID - Type UnspecifiedMN MEDICARE PROVIDER NUMB