Provider Demographics
NPI:1073070702
Name:CHRISTIAN, ASHLEY TALISA
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:TALISA
Last Name:CHRISTIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5001 WARRIOR LN
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901
Mailing Address - Country:US
Mailing Address - Phone:573-686-1200
Mailing Address - Fax:
Practice Address - Street 1:3001 WARRIOR LN
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-8685
Practice Address - Country:US
Practice Address - Phone:573-686-1200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-28
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS897667163W00000X
MS904491363LP0808X
AL1-183314363LP0808X
MO2023010529363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse