Provider Demographics
NPI:1407816143
Name:AMBROSE, KATHLEEN D (NP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:D
Last Name:AMBROSE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64580 VAN DYKE RD
Mailing Address - Street 2:STE C
Mailing Address - City:WASHINGTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48095-2811
Mailing Address - Country:US
Mailing Address - Phone:586-226-6865
Mailing Address - Fax:586-226-6880
Practice Address - Street 1:64580 VAN DYKE RD
Practice Address - Street 2:SUITE C
Practice Address - City:WASHINGTON
Practice Address - State:MI
Practice Address - Zip Code:48095-2857
Practice Address - Country:US
Practice Address - Phone:586-752-9629
Practice Address - Fax:586-752-4099
Is Sole Proprietor?:No
Enumeration Date:2006-03-25
Last Update Date:2017-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI470413564163WG0000X
MI4704131564363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI50-0866503-0OtherBCBS PIN NUMBER
MD4378376Medicaid
MIS85620Medicare UPIN
MIN40180-001Medicare ID - Type UnspecifiedMEDICARE