Provider Demographics
NPI:1033796354
Name:MOURI, ASHLEY TATE (NNP)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:TATE
Last Name:MOURI
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:TATE
Other - Last Name:PALYUKH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NNP
Mailing Address - Street 1:818 KENNEDY DR
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-6536
Mailing Address - Country:US
Mailing Address - Phone:469-667-6901
Mailing Address - Fax:
Practice Address - Street 1:500 W MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75057-3641
Practice Address - Country:US
Practice Address - Phone:469-370-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1031611363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal