Provider Demographics
NPI: | 1205114212 |
---|---|
Name: | KING, ASHLEY NICOLE |
Entity type: | Individual |
Prefix: | |
First Name: | ASHLEY |
Middle Name: | NICOLE |
Last Name: | KING |
Suffix: | |
Gender: | F |
Credentials: | |
Other - Prefix: | |
Other - First Name: | ASHLEY |
Other - Middle Name: | NICOLE |
Other - Last Name: | HARTSTEIN-HORST |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | |
Mailing Address - Street 1: | 14199 110TH TER |
Mailing Address - Street 2: | |
Mailing Address - City: | LARGO |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33774-4442 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 727-644-4707 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 14199 110TH TER |
Practice Address - Street 2: | |
Practice Address - City: | LARGO |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33774-4442 |
Practice Address - Country: | US |
Practice Address - Phone: | 727-644-4707 |
Practice Address - Fax: | |
Is Sole Proprietor?: | Yes |
Enumeration Date: | 2011-07-25 |
Last Update Date: | 2016-01-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
222Q00000X | ||
FL | SI1885 | 2355S0801X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 222Q00000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Developmental Therapist | |
No | 2355S0801X | Speech, Language and Hearing Service Providers | Specialist/Technologist | Speech-Language Assistant |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 006235500 | Medicaid |