1194366161 NPI number — MRS. ASHLY MARIE MEDEIROS APRN

Table of content: MRS. ASHLY MARIE MEDEIROS APRN (NPI 1194366161)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194366161 NPI number — MRS. ASHLY MARIE MEDEIROS APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEDEIROS
Provider First Name:
ASHLY
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194366161
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/12/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
66 KNIGHT LN STE 10
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLISTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05495-9308
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-872-4343
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 WESTWOOD PL STE 110
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRENTWOOD
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37027-7554
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-206-2462
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/01/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP143139 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3000040884 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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