Provider Demographics
NPI:1821643339
Name:CUSTODIO, ASHLEY JENNIFER (APRN)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:JENNIFER
Last Name:CUSTODIO
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4129 N ARMENIA AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6436
Mailing Address - Country:US
Mailing Address - Phone:813-879-3699
Mailing Address - Fax:813-873-8469
Practice Address - Street 1:4129 N ARMENIA AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33607-6436
Practice Address - Country:US
Practice Address - Phone:813-879-3699
Practice Address - Fax:813-873-8469
Is Sole Proprietor?:No
Enumeration Date:2019-08-02
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11003143363LP2300X
FLAPRN11003143363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care