Provider Demographics
NPI:1962865980
Name:AMBLO, JOLANTA TERESA (MD)
Entity Type:Individual
Prefix:
First Name:JOLANTA
Middle Name:TERESA
Last Name:AMBLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 FRANKS WAY
Mailing Address - Street 2:
Mailing Address - City:SHELBURNE
Mailing Address - State:VT
Mailing Address - Zip Code:05482-7144
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BARRE
Practice Address - State:VT
Practice Address - Zip Code:05641-4881
Practice Address - Country:US
Practice Address - Phone:802-479-3302
Practice Address - Fax:802-225-5720
Is Sole Proprietor?:No
Enumeration Date:2016-03-29
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT63491207R00000X, 208M00000X
VT042-0014472207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist