Provider Demographics
NPI:1689904195
Name:STACK, ASHLEY (CNIM)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:STACK
Suffix:
Gender:F
Credentials:CNIM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8133 NOVA DR
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33324-5709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1926 10TH AVE N
Practice Address - Street 2:
Practice Address - City:LAKE WORTH
Practice Address - State:FL
Practice Address - Zip Code:33461-3369
Practice Address - Country:US
Practice Address - Phone:561-540-4458
Practice Address - Fax:561-540-5939
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-05
Last Update Date:2010-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1897246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic