Provider Demographics
NPI:1720293566
Name:AMBROSINO, KIMBERLY (OD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:
Last Name:AMBROSINO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3908 LAKE VILLAGE CV
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-5838
Mailing Address - Country:US
Mailing Address - Phone:662-253-5534
Mailing Address - Fax:
Practice Address - Street 1:6823 ELMORE RD
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671
Practice Address - Country:US
Practice Address - Phone:662-536-3680
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS654152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist