Provider Demographics
NPI:1447775754
Name:MATTHEWS, AMBROSIA
Entity Type:Individual
Prefix:
First Name:AMBROSIA
Middle Name:
Last Name:MATTHEWS
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 1:1605 CLIFFWOOD DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-5001
Mailing Address - Country:US
Mailing Address - Phone:757-510-4336
Mailing Address - Fax:
Practice Address - Street 1:525 S INDEPENDENCE BLVD STE 190
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-1189
Practice Address - Country:US
Practice Address - Phone:757-473-9900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-08
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306604795225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant