Provider Demographics
NPI:1700813292
Name:D'AMBROSIO, MARYELLEN (MS,PMHNP,BC)
Entity Type:Individual
Prefix:MRS
First Name:MARYELLEN
Middle Name:
Last Name:D'AMBROSIO
Suffix:
Gender:F
Credentials:MS,PMHNP,BC
Other - Prefix:MISS
Other - First Name:MARYELLEN
Other - Middle Name:
Other - Last Name:VENERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS,PMHNP,BC
Mailing Address - Street 1:47 KATHLEEN LN
Mailing Address - Street 2:
Mailing Address - City:MOUNT KISCO
Mailing Address - State:NY
Mailing Address - Zip Code:10549-3626
Mailing Address - Country:US
Mailing Address - Phone:914-241-2249
Mailing Address - Fax:
Practice Address - Street 1:1940 COMMERCE ST
Practice Address - Street 2:SUITE 300
Practice Address - City:YORKTOWN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:10598-4428
Practice Address - Country:US
Practice Address - Phone:914-245-0437
Practice Address - Fax:914-245-0438
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF400855363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF400855Medicare UPIN