Basic Information
| Provider Information | |||||||||
| NPI: | 1487990859 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SELF | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | NICHOLE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 32569 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379302569 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656940062 | ||||||||
| FaxNumber: | 8656738007 | ||||||||
| Practice Location | |||||||||
| Address1: | 1819 W CLINCH AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37916 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655245365 | ||||||||
| FaxNumber: | 8656738007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2012 | ||||||||
| LastUpdateDate: | 02/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | APN0000016921 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1530802 | 05 | TN | MEDICAID |