Provider Demographics
NPI:1396135133
Name:AMBAM, EMMACULATE
Entity type:Individual
Prefix:
First Name:EMMACULATE
Middle Name:
Last Name:AMBAM
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 1:3207 TOLEDO PL APT T1
Mailing Address - Street 2:
Mailing Address - City:HYATTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20782-4189
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3207 TOLEDO PL APT T1
Practice Address - Street 2:
Practice Address - City:HYATTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20782-4189
Practice Address - Country:US
Practice Address - Phone:443-570-8278
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-02
Last Update Date:2015-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLPN1006877164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse