Basic Information
| Provider Information | |||||||||
| NPI: | 1356781900 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | N | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NURSE PRACTITIONER | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | ASHLEY | ||||||||
| OtherMiddleName: | N | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NURSE PRACTITIONER | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 121 STACY DRIVE | ||||||||
| Address2: | |||||||||
| City: | PENNINGTON GAP | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242771929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2765461182 | ||||||||
| FaxNumber: | 2765462497 | ||||||||
| Practice Location | |||||||||
| Address1: | 121 STACY DRIVE | ||||||||
| Address2: | |||||||||
| City: | PENNINGTON GAP | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242771929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2765461182 | ||||||||
| FaxNumber: | 2765462497 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2013 | ||||||||
| LastUpdateDate: | 08/07/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3008078 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 0024172166 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.