Provider Demographics
NPI:1073257275
Name:WAGNER SMITH, ASHLEY (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:WAGNER SMITH
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LAT, ATC
Mailing Address - Street 1:2877 S SHERWOOD DR
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36606-2418
Mailing Address - Country:US
Mailing Address - Phone:267-664-2519
Mailing Address - Fax:
Practice Address - Street 1:14001 HURRICANE BLVD
Practice Address - Street 2:
Practice Address - City:IRVINGTON
Practice Address - State:AL
Practice Address - Zip Code:36544-3071
Practice Address - Country:US
Practice Address - Phone:267-664-2519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-24
Last Update Date:2022-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL17432255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer