Provider Demographics
NPI:1164924338
Name:EMERSON, ASHLEY (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:EMERSON
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:
Other - Last Name:LATTANZIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3946 ICE WAY
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46808
Mailing Address - Country:US
Mailing Address - Phone:260-266-4007
Mailing Address - Fax:
Practice Address - Street 1:3946 ICE WAY
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46808
Practice Address - Country:US
Practice Address - Phone:260-266-4007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-05
Last Update Date:2018-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN36002746A2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer