Provider Demographics
NPI:1376142943
Name:CHITTENDEN, ASHLEY B (CPNP-AC/PC)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:B
Last Name:CHITTENDEN
Suffix:
Gender:F
Credentials:CPNP-AC/PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3480 AVIS LN
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38672-2010
Mailing Address - Country:US
Mailing Address - Phone:716-949-2677
Mailing Address - Fax:
Practice Address - Street 1:3480 AVIS LN
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38672-2010
Practice Address - Country:US
Practice Address - Phone:716-949-2677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-23
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12180639363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics