Healthcare Provider Details

I. General information

NPI: 1730879545
Provider Name (Legal Business Name): AMBESON CORNELL AMBE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6100 INDIAN SCHOOL RD NE STE 115
ALBUQUERQUE NM
87110-4181
US

IV. Provider business mailing address

6100 INDIAN SCHOOL RD NE STE 115
ALBUQUERQUE NM
87110-4181
US

V. Phone/Fax

Practice location:
  • Phone: 505-881-4500
  • Fax:
Mailing address:
  • Phone: 505-881-4500
  • Fax: 505-881-5158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number215093
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP74900
License Number StateNM
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1118807
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: