Provider Demographics
NPI:1407502479
Name:WHITEHEAD, ASHLEY LYNN (LMT)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:LYNN
Last Name:WHITEHEAD
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9751 N GOVERNMENT WAY STE 4
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-9645
Mailing Address - Country:US
Mailing Address - Phone:208-696-1330
Mailing Address - Fax:208-684-7834
Practice Address - Street 1:9751 N GOVERNMENT WAY STE 4
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-9645
Practice Address - Country:US
Practice Address - Phone:208-696-1330
Practice Address - Fax:208-684-7834
Is Sole Proprietor?:No
Enumeration Date:2022-02-28
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-4621225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist