Provider Demographics
NPI:1568729770
Name:MATCHACK, ASHLEY M (LPN)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:M
Last Name:MATCHACK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:M
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:6008 PARIS BLVD N
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-4161
Mailing Address - Country:US
Mailing Address - Phone:419-516-9871
Mailing Address - Fax:
Practice Address - Street 1:423 GRAND CIRCUIT BLVD
Practice Address - Street 2:
Practice Address - City:DELAWARE
Practice Address - State:OH
Practice Address - Zip Code:43015-3327
Practice Address - Country:US
Practice Address - Phone:419-516-9871
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-12
Last Update Date:2012-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.147181-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse