Provider Demographics
NPI:1881268761
Name:AMBROSE, STACEY L (MSN, CRNP)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:L
Last Name:AMBROSE
Suffix:
Gender:F
Credentials:MSN, CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 RIDGEWOOD RD STE 180
Mailing Address - Street 2:
Mailing Address - City:WYOMISSING
Mailing Address - State:PA
Mailing Address - Zip Code:19610-1190
Mailing Address - Country:US
Mailing Address - Phone:267-257-5896
Mailing Address - Fax:
Practice Address - Street 1:2201 RIDGEWOOD RD STE 180
Practice Address - Street 2:
Practice Address - City:WYOMISSING
Practice Address - State:PA
Practice Address - Zip Code:19610-1190
Practice Address - Country:US
Practice Address - Phone:267-257-5896
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-17
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP023740363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care