Provider Demographics
NPI:1700489796
Name:AMBROSIUS, LYDIA ANN (CNM,APNP)
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:ANN
Last Name:AMBROSIUS
Suffix:
Gender:F
Credentials:CNM,APNP
Other - Prefix:
Other - First Name:LYDIA
Other - Middle Name:ANN
Other - Last Name:NIKODEM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN,APNP,CNM
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:720 S VANBUREN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3504
Practice Address - Country:US
Practice Address - Phone:920-468-3444
Practice Address - Fax:920-432-6313
Is Sole Proprietor?:No
Enumeration Date:2020-11-20
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI149009-32367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CNM06674OtherAMERICAN MIDWIFERY CERTIFICATION BOARD