Provider Demographics
NPI:1366733289
Name:AMBROSE, ALEXIS V (LPN)
Entity type:Individual
Prefix:MISS
First Name:ALEXIS
Middle Name:V
Last Name:AMBROSE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:483 AUTUMNWOOD DR
Mailing Address - Street 2:APT. A
Mailing Address - City:TIFFIN
Mailing Address - State:OH
Mailing Address - Zip Code:44883-1870
Mailing Address - Country:US
Mailing Address - Phone:419-618-7954
Mailing Address - Fax:
Practice Address - Street 1:483 AUTUMNWOOD DR
Practice Address - Street 2:APT. A
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-1870
Practice Address - Country:US
Practice Address - Phone:419-618-7954
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN. 122275164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse