Provider Demographics
NPI:1013340934
Name:AMBROSINO, KELLY ANN (RPH)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ANN
Last Name:AMBROSINO
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:MARTUCCI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:950 W LANDIS AVE
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08360-3420
Mailing Address - Country:US
Mailing Address - Phone:856-205-0109
Mailing Address - Fax:856-205-0164
Practice Address - Street 1:950 W LANDIS AVE
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-3420
Practice Address - Country:US
Practice Address - Phone:856-205-0109
Practice Address - Fax:856-205-0164
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-14
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ28RI02190100183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist