Provider Demographics
NPI:1164063947
Name:WONNEBERGER, ASHLEY NICOLE
Entity Type:Individual
Prefix:MRS
First Name:ASHLEY
Middle Name:NICOLE
Last Name:WONNEBERGER
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 1:59 VILLAGE OF STONEY RUN APT D
Mailing Address - Street 2:
Mailing Address - City:MAPLE SHADE
Mailing Address - State:NJ
Mailing Address - Zip Code:08052-2159
Mailing Address - Country:US
Mailing Address - Phone:856-689-2907
Mailing Address - Fax:
Practice Address - Street 1:59 VILLAGE OF STONEY RUN APT D
Practice Address - Street 2:
Practice Address - City:MAPLE SHADE
Practice Address - State:NJ
Practice Address - Zip Code:08052-2159
Practice Address - Country:US
Practice Address - Phone:856-689-2907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-03
Last Update Date:2019-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT0143382251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics