Provider Demographics
NPI:1932982360
Name:AMBIANCE AESTHETICS & REJUVENATION
Entity Type:Organization
Organization Name:AMBIANCE AESTHETICS & REJUVENATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:M
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:667-230-3591
Mailing Address - Street 1:10609 LAND TREE DR
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-6633
Mailing Address - Country:US
Mailing Address - Phone:410-299-8955
Mailing Address - Fax:
Practice Address - Street 1:1667 CROFTON CTR STE 8B
Practice Address - Street 2:
Practice Address - City:CROFTON
Practice Address - State:MD
Practice Address - Zip Code:21114-1303
Practice Address - Country:US
Practice Address - Phone:667-230-3591
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care