Provider Demographics
NPI:1619329034
Name:CREEDY, ASHLEY NICOLE
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:NICOLE
Last Name:CREEDY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:NICOLE
Other - Last Name:KOPELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2100 N WINROCK ST
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-5093
Mailing Address - Country:US
Mailing Address - Phone:208-697-1421
Mailing Address - Fax:
Practice Address - Street 1:2100 N WINROCK ST
Practice Address - Street 2:
Practice Address - City:LIBERTY LAKE
Practice Address - State:WA
Practice Address - Zip Code:99019-5093
Practice Address - Country:US
Practice Address - Phone:208-697-1421
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-09
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60311256390200000X
WAAP60704623363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program