Healthcare Provider Details

I. General information

NPI: 1902863624
Provider Name (Legal Business Name): NANCY DIANE AMBS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 11/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3770 GLENKERRY CT
PORTAGE MI
49024-0700
US

IV. Provider business mailing address

61 COMMERCE AVE SW
GRAND RAPIDS MI
49503-4124
US

V. Phone/Fax

Practice location:
  • Phone: 269-329-2887
  • Fax: 269-329-2805
Mailing address:
  • Phone: 616-940-0660
  • Fax: 616-940-1965

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704151927
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: