Provider Demographics
NPI:1285993881
Name:AMBE, ICHOL DEBORAH
Entity type:Individual
Prefix:
First Name:ICHOL
Middle Name:DEBORAH
Last Name:AMBE
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 1:13008 INNISBROOK DR
Mailing Address - Street 2:
Mailing Address - City:BELTSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20705-1196
Mailing Address - Country:US
Mailing Address - Phone:301-231-3048
Mailing Address - Fax:
Practice Address - Street 1:13008 INNISBROOK DR
Practice Address - Street 2:
Practice Address - City:BELTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20705-1196
Practice Address - Country:US
Practice Address - Phone:301-231-3048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-16
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA510328139430374U00000X
DCRN040061363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No374U00000XNursing Service Related ProvidersHome Health Aide