Provider Demographics
NPI:1013147693
Name:AMBROSE, JENNIFER RAE (CRNA)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:RAE
Last Name:AMBROSE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16015 SUNSET BEND CIR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99516-7576
Mailing Address - Country:US
Mailing Address - Phone:612-269-1918
Mailing Address - Fax:
Practice Address - Street 1:4100 LAKE OTIS PKWY
Practice Address - Street 2:SUITE 222
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5229
Practice Address - Country:US
Practice Address - Phone:612-269-1918
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-17
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE101104367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1013147693Medicare UPIN