Provider Demographics
NPI:1780646117
Name:AMBROSIUS, ANITA M (APNP)
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:M
Last Name:AMBROSIUS
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:ANITA
Other - Middle Name:M
Other - Last Name:FOSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:2502 S ASHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54304-5252
Mailing Address - Country:US
Mailing Address - Phone:920-496-4700
Mailing Address - Fax:
Practice Address - Street 1:120 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:KAUKAUNA
Practice Address - State:WI
Practice Address - Zip Code:54130
Practice Address - Country:US
Practice Address - Phone:920-562-6018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2018-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI125242-30163WP2201X
WI1938-033363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI439-53-700Medicaid
07695-0007Medicare PIN
WI439-53-700Medicaid