Healthcare Provider Details

I. General information

NPI: 1295671311
Provider Name (Legal Business Name): AMBUSH LAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4367 HOLLINS FERRY RD STE 1C
BALTIMORE MD
21227-3400
US

IV. Provider business mailing address

4367 HOLLINS FERRY RD STE 1C
BALTIMORE MD
21227-3400
US

V. Phone/Fax

Practice location:
  • Phone: 410-707-5947
  • Fax: 410-707-5947
Mailing address:
  • Phone: 410-707-5947
  • Fax: 410-707-5947

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: JACQUELINE EBONY AMBUSH
Title or Position: OWNER
Credential: DNP
Phone: 410-707-5947