Provider Demographics
NPI:1831293315
Name:ASHLEY, MARY DIANE (RN, APRN,BC)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:DIANE
Last Name:ASHLEY
Suffix:
Gender:F
Credentials:RN, APRN,BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5105 BLAINE ST SE
Mailing Address - Street 2:
Mailing Address - City:KENTWOOD
Mailing Address - State:MI
Mailing Address - Zip Code:49508
Mailing Address - Country:US
Mailing Address - Phone:616-530-3927
Mailing Address - Fax:775-259-2263
Practice Address - Street 1:5105 BLAINE AVE SE
Practice Address - Street 2:
Practice Address - City:KENTWOOD
Practice Address - State:MI
Practice Address - Zip Code:49508-4705
Practice Address - Country:US
Practice Address - Phone:616-530-3927
Practice Address - Fax:775-259-2263
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-12
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704167634363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMA1441067OtherDEA NUMBER