MEDICARE: KATHLEEN D AMBROSE NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WG0000X	General Practice Registered Nurse	470413564	MI
2	363LF0000X	Family Nurse Practitioner	4704131564	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	50-0866503-0	OTHER	MI	BCBS PIN NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1407816143
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KATHLEEN D AMBROSE NP

Provider Business Mailing Address
First Line	:	64580 VAN DYKE RD
Second Line	:	STE C
City	:	WASHINGTON TOWNSHIP
State	:	MI
Zip	:	48095-2811
Country	:	US
Telephone Number	:	586-226-6865
Fax Number	:	586-226-6880

Provider Business Practice Location Address
First Line	:	64580 VAN DYKE RD
Second Line	:	SUITE C
City	:	WASHINGTON
State	:	MI
Zip	:	48095-2857
Country	:	US
Telephone Number	:	586-752-9629
Fax Number	:	586-752-4099

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/25/2006
Last Update Date	:	02/01/2017

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