Provider Demographics
NPI:1548715139
Name:D'AMBROSIO, VALERIE
Entity type:Individual
Prefix:
First Name:VALERIE
Middle Name:
Last Name:D'AMBROSIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3045 PAAS POND LN
Mailing Address - Street 2:
Mailing Address - City:COTTONDALE
Mailing Address - State:FL
Mailing Address - Zip Code:32431-7179
Mailing Address - Country:US
Mailing Address - Phone:352-442-2985
Mailing Address - Fax:
Practice Address - Street 1:2065 HALF DAY RD # T565
Practice Address - Street 2:
Practice Address - City:DEERFIELD
Practice Address - State:IL
Practice Address - Zip Code:60015-1241
Practice Address - Country:US
Practice Address - Phone:352-442-2985
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-24
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLD5168769386102255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2255A2300XOtherSTUDENT