Provider Demographics
NPI:1417521501
Name:BOONNAM, ASHLEY LAUREN (FNP-BC)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:LAUREN
Last Name:BOONNAM
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8905 W LINCOLN AVE STE 501
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53227-2470
Mailing Address - Country:US
Mailing Address - Phone:414-978-2229
Mailing Address - Fax:414-378-2279
Practice Address - Street 1:8905 W LINCOLN AVE STE 501
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2470
Practice Address - Country:US
Practice Address - Phone:414-978-2229
Practice Address - Fax:414-378-2279
Is Sole Proprietor?:No
Enumeration Date:2021-05-13
Last Update Date:2021-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10616-33363LF0000X
WI10616363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100178967Medicaid