Healthcare Provider Details

I. General information

NPI: 1013335546
Provider Name (Legal Business Name): JACQUELINE EBONY AMBUSH PNP BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2014
Last Update Date: 06/01/2015
Certification Date:
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:
Mailing address:
  • Phone: 410-707-5947
  • Fax: 410-609-6672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR117755
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberR117755
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: