Basic Information
| Provider Information | |||||||||
| NPI: | 1689904195 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STACK | ||||||||
| FirstName: | ASHLEY | ||||||||
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| Credential: | CNIM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8133 NOVA DR | ||||||||
| Address2: | |||||||||
| City: | DAVIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333245709 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1926 10TH AVE N | ||||||||
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| City: | LAKE WORTH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334613369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5615404458 | ||||||||
| FaxNumber: | 5615405939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2010 | ||||||||
| LastUpdateDate: | 01/05/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZE0600X | 1897 | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Electroneurodiagnostic |
No ID Information.