Provider Demographics
NPI:1689495780
Name:AMBROSE, OLGA
Entity type:Individual
Prefix:
First Name:OLGA
Middle Name:
Last Name:AMBROSE
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 1:6405 S 3000 E STE 100
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6975
Mailing Address - Country:US
Mailing Address - Phone:310-359-2931
Mailing Address - Fax:
Practice Address - Street 1:6405 S 3000 E STE 100
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84121-6975
Practice Address - Country:US
Practice Address - Phone:310-359-2931
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT126414444701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist