Basic Information
| Provider Information | |||||||||
| NPI: | 1073978839 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AMBROSE | ||||||||
| FirstName: | ANGEL | ||||||||
| MiddleName: | LB | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSN, APRN, FNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BOISSEAU, MARTIN, WAKE | ||||||||
| OtherFirstName: | ANGEL | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6355 S BUFFALO DR FL 3 | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891132133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022163346 | ||||||||
| FaxNumber: | 7026716883 | ||||||||
| Practice Location | |||||||||
| Address1: | 1397 S LOOP RD | ||||||||
| Address2: | |||||||||
| City: | PAHRUMP | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890484729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757275500 | ||||||||
| FaxNumber: | 7757275696 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2015 | ||||||||
| LastUpdateDate: | 10/14/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WE0003X | 36717 | AK | N | Nursing Service Providers | Registered Nurse | Emergency | 363LF0000X | 829703 | NV | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 829703 | 01 | NV | STATE LICENSE | OTHER | 1073978839 | 05 | NV | MEDICAID | 36717 | 01 | AK | NURSING LICENSE | OTHER |