Provider Demographics
NPI:1467021816
Name:FATHEREE, ASHLEY
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:FATHEREE
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 1:11850 BLACKFOOT ST NW STE 100
Mailing Address - Street 2:
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2774
Mailing Address - Country:US
Mailing Address - Phone:763-712-2100
Mailing Address - Fax:
Practice Address - Street 1:11850 BLACKFOOT ST NW STE 100
Practice Address - Street 2:
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2774
Practice Address - Country:US
Practice Address - Phone:763-712-2100
Practice Address - Fax:763-712-2190
Is Sole Proprietor?:No
Enumeration Date:2021-06-21
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024186462363L00000X
DCRN1051347363LA2200X
MN10482363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health