Provider Demographics
NPI:1124471776
Name:AMBROISE, RENETTE (RN)
Entity type:Individual
Prefix:
First Name:RENETTE
Middle Name:
Last Name:AMBROISE
Suffix:
Gender:
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:998 CROOKED HILL RD
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-1019
Mailing Address - Country:US
Mailing Address - Phone:631-761-2177
Mailing Address - Fax:
Practice Address - Street 1:265 BROADHOLLOW RD STE 101
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-4833
Practice Address - Country:US
Practice Address - Phone:914-216-7585
Practice Address - Fax:914-216-7585
Is Sole Proprietor?:No
Enumeration Date:2016-07-19
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY595342163W00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY$$$$$$$$$OtherNPI
NY$$$$$$$$$OtherNPI