Provider Demographics
NPI:1154723476
Name:AMBROSE, RENA (PTA)
Entity type:Individual
Prefix:
First Name:RENA
Middle Name:
Last Name:AMBROSE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:255 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-2724
Mailing Address - Country:US
Mailing Address - Phone:973-985-8392
Mailing Address - Fax:
Practice Address - Street 1:255 BROAD ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-2724
Practice Address - Country:US
Practice Address - Phone:973-985-8392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-17
Last Update Date:2014-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QB00272500225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant