Provider Demographics
NPI:1275782898
Name:ASHBY, STACY AILEEN I
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:AILEEN
Last Name:ASHBY
Suffix:I
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:PO BOX 370
Mailing Address - Street 2:
Mailing Address - City:FORTSON
Mailing Address - State:GA
Mailing Address - Zip Code:31808-0370
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:706-494-3008
Practice Address - Street 1:1900 10TH AVE STE 211
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31901-3604
Practice Address - Country:US
Practice Address - Phone:706-507-2307
Practice Address - Fax:706-507-2178
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-18
Last Update Date:2020-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAUD003580231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003107802Medicaid
GA511I640058OtherMEDICARE PTAN
AL126556Medicaid