Provider Demographics
NPI:1386221794
Name:BERTAGNOLE, ASHLEY ANN (DPT)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:ANN
Last Name:BERTAGNOLE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:ANN
Other - Last Name:QUONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:640 N THORNTON ST
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-7495
Mailing Address - Country:US
Mailing Address - Phone:208-773-2888
Mailing Address - Fax:208-806-0222
Practice Address - Street 1:927 E POLSTON AVE
Practice Address - Street 2:STE 201
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854
Practice Address - Country:US
Practice Address - Phone:208-773-2888
Practice Address - Fax:208-806-0222
Is Sole Proprietor?:No
Enumeration Date:2021-03-24
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-3358225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDPT-3358OtherPHYSICAL THERAPY LICENSE