Healthcare Provider Details

I. General information

NPI: 1134865595
Provider Name (Legal Business Name): AMBLE MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2022
Last Update Date: 09/27/2024
Certification Date: 09/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9980 S 300 W STE 300
SANDY UT
84070-3654
US

IV. Provider business mailing address

9980 S 300 W STE 300
SANDY UT
84070-3654
US

V. Phone/Fax

Practice location:
  • Phone: 801-253-6886
  • Fax:
Mailing address:
  • Phone: 801-253-6886
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: RYAN SCOTT ELLSWORTH
Title or Position: CEO
Credential: DPM
Phone: 801-253-6886