Provider Demographics
NPI:1790305613
Name:AMBROSE, BRANDI (HAIR LOSS SPT)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:
Last Name:AMBROSE
Suffix:
Gender:F
Credentials:HAIR LOSS SPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2640 E MARTHA PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60633-2092
Mailing Address - Country:US
Mailing Address - Phone:773-899-8561
Mailing Address - Fax:
Practice Address - Street 1:3408 W 95TH ST
Practice Address - Street 2:
Practice Address - City:EVERGREEN PK
Practice Address - State:IL
Practice Address - Zip Code:60805-2204
Practice Address - Country:US
Practice Address - Phone:773-621-1199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-21
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management