Provider Demographics
NPI:1508463167
Name:DISRUD, ASHLEY KNIGHT (LMT)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:KNIGHT
Last Name:DISRUD
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 1:120 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:OREGON
Mailing Address - State:WI
Mailing Address - Zip Code:53575-1405
Mailing Address - Country:US
Mailing Address - Phone:608-515-8125
Mailing Address - Fax:
Practice Address - Street 1:120 N MAIN ST
Practice Address - Street 2:
Practice Address - City:OREGON
Practice Address - State:WI
Practice Address - Zip Code:53575-1405
Practice Address - Country:US
Practice Address - Phone:608-515-8125
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-07
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI13791-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist