Provider Demographics
NPI:1104315910
Name:AMBROSE, LAUREL ALEXIS
Entity type:Individual
Prefix:
First Name:LAUREL
Middle Name:ALEXIS
Last Name:AMBROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 780125
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19178-0125
Mailing Address - Country:US
Mailing Address - Phone:804-922-4844
Mailing Address - Fax:804-327-3065
Practice Address - Street 1:501 N 2ND ST FL 3
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23219-1359
Practice Address - Country:US
Practice Address - Phone:804-828-9452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-07
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01022059392084P0800X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry