Healthcare Provider Details

I. General information

NPI: 1386191740
Provider Name (Legal Business Name): LEAH AMBROSE P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2016
Last Update Date: 09/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 AIRPORT BLVD SUITE C138
MOBILE AL
36608-6705
US

IV. Provider business mailing address

6701 AIRPORT BLVD SUITE C138
MOBILE AL
36608-6705
US

V. Phone/Fax

Practice location:
  • Phone: 251-287-2176
  • Fax: 251-287-2279
Mailing address:
  • Phone: 251-287-2176
  • Fax: 251-287-2279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberTA.1824
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: