Provider Demographics
NPI:1639711856
Name:MARSHALL, AYASHA NICHELLE
Entity Type:Individual
Prefix:
First Name:AYASHA
Middle Name:NICHELLE
Last Name:MARSHALL
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 1:4929 W FOND DU LAC AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53216-2324
Mailing Address - Country:US
Mailing Address - Phone:414-383-4486
Mailing Address - Fax:414-871-2552
Practice Address - Street 1:4929 W FOND DU LAC AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53216-2324
Practice Address - Country:US
Practice Address - Phone:414-383-4486
Practice Address - Fax:414-871-2552
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI6405893873Medicaid