Provider Demographics
NPI:1649463290
Name:AMBROSE, LISA PAIGE (PTA)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:PAIGE
Last Name:AMBROSE
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3242 QUAIL POINTE DR
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27858-7335
Mailing Address - Country:US
Mailing Address - Phone:252-217-5301
Mailing Address - Fax:
Practice Address - Street 1:2200 LANDOVER PL
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:VA
Practice Address - Zip Code:24501-2116
Practice Address - Country:US
Practice Address - Phone:434-846-4626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-27
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3876225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant