Provider Demographics
NPI:1811993991
Name:AMBROSE, MARY ANN (MSN, FNP-C)
Entity type:Individual
Prefix:
First Name:MARY ANN
Middle Name:
Last Name:AMBROSE
Suffix:
Gender:F
Credentials:MSN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 SHADOW CREEK LN
Mailing Address - Street 2:
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93446-1922
Mailing Address - Country:US
Mailing Address - Phone:805-748-5663
Mailing Address - Fax:
Practice Address - Street 1:145 SHADOW CREEK LN
Practice Address - Street 2:
Practice Address - City:PASO ROBLES
Practice Address - State:CA
Practice Address - Zip Code:93446-1922
Practice Address - Country:US
Practice Address - Phone:805-748-5663
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-23
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP12654363LF0000X
AZRN094333163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5854236Medicaid
CAP00011916OtherMEDICARE RAILROAD CARRIER
CA5854236Medicaid
CAP00011916OtherMEDICARE RAILROAD CARRIER