Basic Information
| Provider Information | |||||||||
| NPI: | 1912470915 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AJAME | ||||||||
| FirstName: | ARABEL | ||||||||
| MiddleName: | AMBANG | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4412 WHITMORE LN | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450148554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012562614 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4412 WHITMORE LN | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 450148554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012562614 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2019 | ||||||||
| LastUpdateDate: | 01/02/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | 17029.MEDS-IV | OH | Y | Nursing Service Providers | Licensed Practical Nurse |
ID Information
| ID | Type | State | Issuer | Description | UL273679 | 05 | OH | MEDICAID |