Provider Demographics
NPI:1013335546
Name:AMBUSH, JACQUELINE EBONY (PNP BC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:EBONY
Last Name:AMBUSH
Suffix:
Gender:F
Credentials:PNP BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4367 HOLLINS FERRY RD STE 1C
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21227-3400
Mailing Address - Country:US
Mailing Address - Phone:410-707-5947
Mailing Address - Fax:410-609-6672
Practice Address - Street 1:4367 HOLLINS FERRY RD
Practice Address - Street 2:STE.1C
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21227-3400
Practice Address - Country:US
Practice Address - Phone:410-707-5947
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2015-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR117755363LP0200X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR117755OtherMARYLAND BOARD OF NURSING