Basic Information
Provider Information | |||||||||
NPI: | 1144325648 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AMBROSY | ||||||||
FirstName: | NAN | ||||||||
MiddleName: | L | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DNP, ARNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | AMBROSY | ||||||||
OtherFirstName: | NAN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DNP, ARNP | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 2750 SAINT FRANCIS DR | ||||||||
Address2: |   | ||||||||
City: | WATERLOO | ||||||||
State: | IA | ||||||||
PostalCode: | 507025644 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3192728922 | ||||||||
FaxNumber: | 3192728929 | ||||||||
Practice Location | |||||||||
Address1: | 2750 SAINT FRANCIS DR | ||||||||
Address2: |   | ||||||||
City: | WATERLOO | ||||||||
State: | IA | ||||||||
PostalCode: | 507025644 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3192728922 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/13/2006 | ||||||||
LastUpdateDate: | 03/01/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/01/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | 53-74864 | KS | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 364SP0808X | 53-45383 | KS | N |   | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health | 364SP0809X | T128919 | IA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health, Adult | 363LP0808X | G128919 | IA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
ID | Type | State | Issuer | Description | 0704914 | 05 | IA |   | MEDICAID | 100450710C | 05 | KS |   | MEDICAID | 161308 | 01 | KS | BLUE CROSS AND BLUE SHIEL | OTHER |