Provider Demographics
NPI:1790322436
Name:AMBROSCH, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:AMBROSCH
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 1:850 W IRONWOOD DR STE 202
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4903
Mailing Address - Country:US
Mailing Address - Phone:208-664-2175
Mailing Address - Fax:208-664-1226
Practice Address - Street 1:1812 N LAKEWOOD DR STE 100
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2635
Practice Address - Country:US
Practice Address - Phone:208-966-4476
Practice Address - Fax:208-966-4475
Is Sole Proprietor?:No
Enumeration Date:2019-12-02
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPT7061OtherSTATE LICENSE