Provider Demographics
NPI:1386033652
Name:AMBLER, MELISSA
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:AMBLER
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 1:103 W BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-4703
Mailing Address - Country:US
Mailing Address - Phone:865-273-1752
Mailing Address - Fax:865-273-1755
Practice Address - Street 1:349 BMH PHYSICIANS OFFICE BLDG
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37804-5820
Practice Address - Country:US
Practice Address - Phone:865-980-5044
Practice Address - Fax:865-980-5090
Is Sole Proprietor?:No
Enumeration Date:2015-01-09
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000019390363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ012639Medicaid
TNI103504011Medicare PIN
TNQ012639Medicaid