Provider Demographics
NPI:1629532551
Name:CHURCH, ASHLEY MARIE (FNP)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MARIE
Last Name:CHURCH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:MARIE
Other - Last Name:LEIJA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:P.O. BOX 961205
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76161-1205
Mailing Address - Country:US
Mailing Address - Phone:817-740-8450
Mailing Address - Fax:
Practice Address - Street 1:1250 8TH AVE STE 320
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4139
Practice Address - Country:US
Practice Address - Phone:817-924-2111
Practice Address - Fax:817-546-3980
Is Sole Proprietor?:No
Enumeration Date:2019-01-24
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP140391363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner