Provider Demographics
NPI:1568989069
Name:ASHWELL, LARISSA MAE
Entity Type:Individual
Prefix:MRS
First Name:LARISSA
Middle Name:MAE
Last Name:ASHWELL
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 1:448 IRVINE ST
Mailing Address - Street 2:
Mailing Address - City:CHIPPEWA FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54729-3120
Mailing Address - Country:US
Mailing Address - Phone:715-226-0777
Mailing Address - Fax:
Practice Address - Street 1:101 N BRIDGE ST STE 1
Practice Address - Street 2:
Practice Address - City:CHIPPEWA FALLS
Practice Address - State:WI
Practice Address - Zip Code:54729-2483
Practice Address - Country:US
Practice Address - Phone:715-226-0775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI224900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224900000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMastectomy Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI82-2373409Medicaid