Provider Demographics
NPI:1780230631
Name:GEFFRARD, ASHLEY MOAB
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MOAB
Last Name:GEFFRARD
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 1:18323 ARCADE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-1501
Mailing Address - Country:US
Mailing Address - Phone:516-884-0445
Mailing Address - Fax:
Practice Address - Street 1:18323 ARCADE AVE
Practice Address - Street 2:
Practice Address - City:SAINT ALBANS
Practice Address - State:NY
Practice Address - Zip Code:11412-1501
Practice Address - Country:US
Practice Address - Phone:516-884-0445
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist