Provider Demographics
NPI:1508291261
Name:TEAGUE, ASHLEY ELIZABETH (LAC)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:ELIZABETH
Last Name:TEAGUE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:ELIZABETH
Other - Last Name:ITTERLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC
Mailing Address - Street 1:1850 ROUTE 112 STE M
Mailing Address - Street 2:
Mailing Address - City:CORAM
Mailing Address - State:NY
Mailing Address - Zip Code:11727-2232
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1850 ROUTE 112 STE M
Practice Address - Street 2:
Practice Address - City:CORAM
Practice Address - State:NY
Practice Address - Zip Code:11727-2232
Practice Address - Country:US
Practice Address - Phone:631-629-5433
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-12
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005046171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist