Provider Demographics
NPI:1689096463
Name:JOHNK, ASHLEY
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:JOHNK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:
Other - Last Name:WALLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:4255 30TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-8427
Mailing Address - Country:US
Mailing Address - Phone:701-478-8950
Mailing Address - Fax:701-478-8920
Practice Address - Street 1:4255 30TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8427
Practice Address - Country:US
Practice Address - Phone:701-478-8950
Practice Address - Fax:701-478-8920
Is Sole Proprietor?:No
Enumeration Date:2014-01-13
Last Update Date:2014-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1503225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist