Provider Demographics
NPI:1932322815
Name:AMBROSIUS, KELLY (CST,CFA,RSA)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:AMBROSIUS
Suffix:
Gender:M
Credentials:CST,CFA,RSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 362
Mailing Address - Street 2:
Mailing Address - City:WADSWORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60083-0362
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:800-560-8374
Practice Address - Street 1:39067 N CAROLINE AVE
Practice Address - Street 2:#362
Practice Address - City:WADSWORTH
Practice Address - State:IL
Practice Address - Zip Code:60083-7728
Practice Address - Country:US
Practice Address - Phone:800-560-8374
Practice Address - Fax:800-560-8374
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL238.00009363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL61-1409473OtherFEIN