Provider Demographics
NPI:1114799418
Name:GREEN, ASHLEY L
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:L
Last Name:GREEN
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 1:528 ROYAL CREST DR
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-4244
Mailing Address - Country:US
Mailing Address - Phone:423-316-5533
Mailing Address - Fax:
Practice Address - Street 1:528 ROYAL CREST DR
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-4244
Practice Address - Country:US
Practice Address - Phone:423-316-5533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-30
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN095559697172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver