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General NPI Number Information
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NPI Number | 1558677971
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Entity Type | Individual
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Provider Name | AUTUMN ANN AMBRODAY D.O.
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Gender | Female
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Dates
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Enumeration Date | 08/23/2010
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Last Update Date | 11/23/2016
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Provider Practice Location Address
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Address Line | 40520 COUNTY HIGHWAY 34 WHITE EARTH TRIBAL MHC
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City | OGEMA
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State | MN
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Zip | 56569-9612
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Country | US
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Telephone | 218-983-6325
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Fax | 952-479-1443
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Provider Business Mailing Address
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Address Line | 40520 COUNTY HIGHWAY 34 WHITE EARTH TRIBAL MHC
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City | OGEMA
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State | MN
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Zip | 56569-9612
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Country | US
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Telephone | 218-983-6325
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Fax | 952-479-1443
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 58284
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 6248
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License Number State | AZ
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