Provider Demographics
NPI:1164930087
Name:LEUTZE, ASHLEY JEAN NICHOLE (PA)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:JEAN NICHOLE
Last Name:LEUTZE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6006 BRAYFORD DR
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-8014
Mailing Address - Country:US
Mailing Address - Phone:248-410-9192
Mailing Address - Fax:
Practice Address - Street 1:1164 E HOME RD STE J
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OH
Practice Address - Zip Code:45503-2726
Practice Address - Country:US
Practice Address - Phone:937-342-9260
Practice Address - Fax:937-342-9262
Is Sole Proprietor?:No
Enumeration Date:2018-01-12
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-005403RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant