Healthcare Provider Details

I. General information

NPI: 1235054222
Provider Name (Legal Business Name): KAITLYN AMBROSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2026
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3827 JIMMY LEE SMITH PKWY STE 122
HIRAM GA
30141-2804
US

IV. Provider business mailing address

3800 CENTER POINT PL
CENTER POINT AL
35215-1334
US

V. Phone/Fax

Practice location:
  • Phone: 770-943-1142
  • Fax:
Mailing address:
  • Phone: 205-936-5150
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTH12783
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: