Provider Demographics
NPI:1598943383
Name:AMBROISE, EVELYNE (LPN)
Entity Type:Individual
Prefix:
First Name:EVELYNE
Middle Name:
Last Name:AMBROISE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 EAGLES NEST DR
Mailing Address - Street 2:0
Mailing Address - City:HIRAM
Mailing Address - State:GA
Mailing Address - Zip Code:30141-3562
Mailing Address - Country:US
Mailing Address - Phone:770-635-8173
Mailing Address - Fax:770-635-8173
Practice Address - Street 1:111 EAGLES NEST DR
Practice Address - Street 2:0
Practice Address - City:HIRAM
Practice Address - State:GA
Practice Address - Zip Code:30141-3562
Practice Address - Country:US
Practice Address - Phone:770-635-8173
Practice Address - Fax:770-635-8173
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-05
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN074773164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse