Provider Demographics
NPI:1861846800
Name:FEDUSENKO, ASHLEY LAUREN
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:LAUREN
Last Name:FEDUSENKO
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 1:7887 EDEN CT
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-4865
Mailing Address - Country:US
Mailing Address - Phone:423-785-7637
Mailing Address - Fax:
Practice Address - Street 1:979 E 3RD ST STE A540A550
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2136
Practice Address - Country:US
Practice Address - Phone:423-778-2867
Practice Address - Fax:423-778-8182
Is Sole Proprietor?:No
Enumeration Date:2016-04-15
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA86562207Q00000X
TN60391207Q00000X, 207QH0002X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program