Healthcare Provider Details

I. General information

NPI: 1255901872
Provider Name (Legal Business Name): MIRIAM SIRI A AMBE PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/27/2021
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 N CHARLES ST
TOWSON MD
21204-6819
US

IV. Provider business mailing address

849 FAIRMOUNT AVE FL 5
TOWSON MD
21286-2624
US

V. Phone/Fax

Practice location:
  • Phone: 410-938-5000
  • Fax:
Mailing address:
  • Phone: 443-377-5273
  • Fax: 443-659-2429

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR225144
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: