Provider Demographics
NPI:1912374174
Name:KOVALICK, ASHLI (FNP-C)
Entity Type:Individual
Prefix:
First Name:ASHLI
Middle Name:
Last Name:KOVALICK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 MARY VANCE DR
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-6226
Mailing Address - Country:US
Mailing Address - Phone:662-377-6275
Mailing Address - Fax:
Practice Address - Street 1:2394 MCCULLOUGH BLVD
Practice Address - Street 2:
Practice Address - City:BELDEN
Practice Address - State:MS
Practice Address - Zip Code:38826-9579
Practice Address - Country:US
Practice Address - Phone:662-205-3023
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-24
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR872383363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08382811Medicaid