Provider Demographics
NPI:1538257779
Name:AMBERG, ANNE H (APRN)
Entity type:Individual
Prefix:MS
First Name:ANNE
Middle Name:H
Last Name:AMBERG
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 POMFRET ST
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-1836
Mailing Address - Country:US
Mailing Address - Phone:860-928-6541
Mailing Address - Fax:860-963-6450
Practice Address - Street 1:320 POMFRET ST
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-1834
Practice Address - Country:US
Practice Address - Phone:860-928-6541
Practice Address - Fax:860-963-6450
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000121367A00000X
CT000390363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT012100OtherCONNECTICARE
CT244029OtherHEALTHNET
CT004200573Medicaid
CT400CNM121CT01OtherBC/BS
CT000390OtherCT LICENSE