Healthcare Provider Details

I. General information

NPI: 1124471776
Provider Name (Legal Business Name): RENETTE AMBROISE R.N
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2016
Last Update Date: 09/29/2026
Certification Date: 04/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

265 BROADHOLLOW RD STE 101
MELVILLE NY
11747-4833
US

IV. Provider business mailing address

998 CROOKED HILL RD
BRENTWOOD NY
11717-1019
US

V. Phone/Fax

Practice location:
  • Phone: 914-216-7585
  • Fax: 914-216-7585
Mailing address:
  • Phone: 631-761-2177
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number595342
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number595342
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: