Provider Demographics
NPI:1407918758
Name:AMBROSE, SANDRA A (NUTRITIONIST)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:A
Last Name:AMBROSE
Suffix:
Gender:F
Credentials:NUTRITIONIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 QUINCY AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-2803
Mailing Address - Country:US
Mailing Address - Phone:508-941-6412
Mailing Address - Fax:508-941-6413
Practice Address - Street 1:130 QUINCY AVE
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-2803
Practice Address - Country:US
Practice Address - Phone:508-941-6412
Practice Address - Fax:508-941-6413
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2020-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1312133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAMT0137Medicare ID - Type Unspecified