Provider Demographics
NPI:1548586092
Name:ANDERSON, ASHLEA A (NP)
Entity Type:Individual
Prefix:
First Name:ASHLEA
Middle Name:A
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ASHLEA
Other - Middle Name:GRACE
Other - Last Name:ADDISON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:100 N HUMPHREYS BLVD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-2146
Mailing Address - Country:US
Mailing Address - Phone:901-683-0055
Mailing Address - Fax:901-685-9718
Practice Address - Street 1:100 N HUMPHREYS BLVD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-2146
Practice Address - Country:US
Practice Address - Phone:901-683-0055
Practice Address - Fax:901-685-9718
Is Sole Proprietor?:No
Enumeration Date:2010-04-08
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN150520163W00000X
TN14859363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08933723Medicaid
TN1519202Medicaid
TN4268462OtherTN BCBS
TN1519202Medicaid
MS302I503602Medicare PIN