Provider Demographics
NPI:1346824307
Name:SOUTHERLAND, ASHLEY SUZANNE (LPN)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:SUZANNE
Last Name:SOUTHERLAND
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1748 W PIKE ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26301-2344
Mailing Address - Country:US
Mailing Address - Phone:423-470-5231
Mailing Address - Fax:
Practice Address - Street 1:706 OAKMOUND RD
Practice Address - Street 2:
Practice Address - City:CLARKSBURG
Practice Address - State:WV
Practice Address - Zip Code:26301-9398
Practice Address - Country:US
Practice Address - Phone:304-622-7511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-06
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN73509164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse