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General NPI Number Information
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NPI Number | 1295671311
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Entity Type | Organization
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Legal Business Name | AMBUSH LAB
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Dates
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Enumeration Date | 04/29/2026
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Last Update Date | 04/29/2026
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Provider Practice Location Address
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Address Line | 4367 HOLLINS FERRY RD STE 1C
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City | BALTIMORE
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State | MD
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Zip | 21227-3400
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Country | US
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Telephone | 410-707-5947
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Fax | 410-707-5947
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Provider Business Mailing Address
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Address Line | 4367 HOLLINS FERRY RD STE 1C
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City | BALTIMORE
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State | MD
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Zip | 21227-3400
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Country | US
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Telephone | 410-707-5947
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Fax | 410-707-5947
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Authorized Official
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Title or Position | OWNER
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Name | JACQUELINE EBONY AMBUSH
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Credential | DNP
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Telephone | 410-707-5947
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207QA0000X
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Taxonomy Name | Adolescent Medicine (Family Medicine) Physician
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License Number |
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License Number State |
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