Basic Information
| Provider Information | |||||||||
| NPI: | 1619513116 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COFFEY | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4732 SEBRING DR | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809113636 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2542581697 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1915 AEROTECH DR STE 190 | ||||||||
| Address2: | |||||||||
| City: | COLORADO SPRINGS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 809164213 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7193015100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2019 | ||||||||
| LastUpdateDate: | 11/20/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | 19-102136 | CO | Y |
ID Information
| ID | Type | State | Issuer | Description | 1790211605 | 05 | CO | MEDICAID |