Basic Information
| Provider Information | |||||||||
| NPI: | 1538257779 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AMBERG | ||||||||
| FirstName: | ANNE | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 320 POMFRET ST | ||||||||
| Address2: | |||||||||
| City: | PUTNAM | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062601836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609286541 | ||||||||
| FaxNumber: | 8609636450 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 POMFRET ST | ||||||||
| Address2: | |||||||||
| City: | PUTNAM | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062601834 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609286541 | ||||||||
| FaxNumber: | 8609636450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 11/04/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | 000121 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife | 363LA2200X | 000390 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 012100 | 01 | CT | CONNECTICARE | OTHER | 244029 | 01 | CT | HEALTHNET | OTHER | 004200573 | 05 | CT | MEDICAID | 400CNM121CT01 | 01 | CT | BC/BS | OTHER | 000390 | 01 | CT | CT LICENSE | OTHER |