Provider Demographics
NPI:1154031623
Name:AMBROSINO, KELLY MARIE
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:MARIE
Last Name:AMBROSINO
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:MARIE
Other - Last Name:SKINNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C, BSN-RN
Mailing Address - Street 1:100 NASSAU RD APT 1
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-3682
Mailing Address - Country:US
Mailing Address - Phone:845-264-1481
Mailing Address - Fax:
Practice Address - Street 1:400 PARK AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-3751
Practice Address - Country:US
Practice Address - Phone:631-261-3322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-24
Last Update Date:2022-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF350436363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily