Provider Demographics
NPI:1760916837
Name:CUNNINGHAM, AMBRI CORLETT (ATC)
Entity Type:Individual
Prefix:
First Name:AMBRI
Middle Name:CORLETT
Last Name:CUNNINGHAM
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:762 E 800 N
Mailing Address - Street 2:
Mailing Address - City:GENOLA
Mailing Address - State:UT
Mailing Address - Zip Code:84655-5056
Mailing Address - Country:US
Mailing Address - Phone:801-995-0422
Mailing Address - Fax:
Practice Address - Street 1:762 E 800 N
Practice Address - Street 2:
Practice Address - City:GENOLA
Practice Address - State:UT
Practice Address - Zip Code:84655-5056
Practice Address - Country:US
Practice Address - Phone:801-995-0422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UTBOC268718405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional