Individual
KELLY AMBROSIUS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CST,CFA,RSA
Contact information
Practice address
39067 N CAROLINE AVE, #362, WADSWORTH, IL 60083-7728
(800) 560-8374
(800) 560-8374
Mailing address
PO BOX 362, WADSWORTH, IL 60083-0362
(800) 560-8374
Taxonomy
Speciality
Code
Description
License number
State
363AS0400X
Surgical Physician Assistant
Primary
238.00009
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
61-1409473
FEIN
IL
Enumeration date
04/10/2007
Last updated
04/01/2015
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