Provider Demographics
NPI:1215130331
Name:AMBROGI, KIM M
Entity type:Individual
Prefix:MISS
First Name:KIM
Middle Name:M
Last Name:AMBROGI
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 1:3600 LAKE BAYSHORE DR UNIT 102
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34205-9000
Mailing Address - Country:US
Mailing Address - Phone:941-447-5083
Mailing Address - Fax:941-756-3718
Practice Address - Street 1:3600 LAKE BAYSHORE DR UNIT 102
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34205-9000
Practice Address - Country:US
Practice Address - Phone:941-447-5083
Practice Address - Fax:941-756-3718
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL229839385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child