Provider Demographics
NPI:1255700696
Name:AMBROSIO, SAMARA
Entity type:Individual
Prefix:
First Name:SAMARA
Middle Name:
Last Name:AMBROSIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 HARVEST HILL RD
Mailing Address - Street 2:
Mailing Address - City:WEST SIMSBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06092-2221
Mailing Address - Country:US
Mailing Address - Phone:860-882-8857
Mailing Address - Fax:
Practice Address - Street 1:400 CAPITAL BLVD FL 3
Practice Address - Street 2:
Practice Address - City:ROCKY HILL
Practice Address - State:CT
Practice Address - Zip Code:06067-3576
Practice Address - Country:US
Practice Address - Phone:888-697-9058
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-16
Last Update Date:2015-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006294363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily