Provider Demographics
NPI:1821397811
Name:FOGWELL, ASHLEY MARIE-LOUISE (ASHLEY FOGWELL)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MARIE-LOUISE
Last Name:FOGWELL
Suffix:
Gender:F
Credentials:ASHLEY FOGWELL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5680 S 152ND ST
Mailing Address - Street 2:APT 10
Mailing Address - City:TUKWILA
Mailing Address - State:WA
Mailing Address - Zip Code:98188-2481
Mailing Address - Country:US
Mailing Address - Phone:515-422-6419
Mailing Address - Fax:
Practice Address - Street 1:4122 FACTORIA BLVD SE
Practice Address - Street 2:SUITE 203
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98006-4200
Practice Address - Country:US
Practice Address - Phone:425-590-9619
Practice Address - Fax:425-590-9641
Is Sole Proprietor?:No
Enumeration Date:2011-03-16
Last Update Date:2013-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60210193225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist