Provider Demographics
NPI:1346893666
Name:LONGSTREET, ASHLEY
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:LONGSTREET
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 1:3340 POPLAR AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38111-4657
Mailing Address - Country:US
Mailing Address - Phone:901-643-1843
Mailing Address - Fax:901-284-0854
Practice Address - Street 1:3340 POPLAR AVE STE 120
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38111-4657
Practice Address - Country:US
Practice Address - Phone:901-643-1843
Practice Address - Fax:901-284-0854
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-17
Last Update Date:2020-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1000000024400251S00000X
TN190002954251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251E00000XAgenciesHome Health