Provider Demographics
NPI:1639131493
Name:FORREST, ASHLEY (PT, MS PT)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:FORREST
Suffix:
Gender:F
Credentials:PT, MS PT
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:LANIER
Other - Last Name:CLARK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT, MS PT
Mailing Address - Street 1:PO BOX 69030
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-9030
Mailing Address - Country:US
Mailing Address - Phone:757-873-2302
Mailing Address - Fax:757-873-2306
Practice Address - Street 1:612 DENBIGH BLVD
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23608-4416
Practice Address - Country:US
Practice Address - Phone:757-874-0032
Practice Address - Fax:757-874-0127
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305202843225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA8937087Medicaid
VA192948OtherBCBS PHYSICAL THERAPY
VA7177270OtherAETNA
VA650022190OtherRAILROAD MEDICARE
VA650022190OtherRAILROAD MEDICARE
VA8937087Medicaid
VA7177270OtherAETNA
VA650000450Medicare PIN