Provider Demographics
NPI:1285242040
Name:AMBROSE, BRANDON (PMHNP-BC)
Entity type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:
Last Name:AMBROSE
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 KENSINGTON SQ # A
Mailing Address - Street 2:
Mailing Address - City:NEW KENSINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15068-6443
Mailing Address - Country:US
Mailing Address - Phone:878-847-7179
Mailing Address - Fax:
Practice Address - Street 1:3 KENSINGTON SQ # A
Practice Address - Street 2:
Practice Address - City:NEW KENSINGTON
Practice Address - State:PA
Practice Address - Zip Code:15068-6443
Practice Address - Country:US
Practice Address - Phone:878-847-7179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-17
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN627220163WC0200X
PASP022299363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine