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General NPI Number Information
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NPI Number | 1891005781
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Entity Type | Individual
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Provider Name | MARYBETH AMBROSE
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Gender | Female
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Dates
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Enumeration Date | 10/14/2010
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Last Update Date | 10/14/2010
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Provider Practice Location Address
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Address Line | 1706 E AMBER LN
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City | URBANA
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State | IL
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Zip | 61802-6907
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Country | US
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Telephone | 217-328-0116
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Fax |
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Provider Business Mailing Address
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Address Line | 904 S VINE ST
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City | URBANA
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State | IL
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Zip | 61801-5013
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Country | US
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Telephone |
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Fax |
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 160.002119
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License Number State | IL
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