Provider Demographics
NPI:1295435717
Name:FAVRE, ASHLEY RYAN (RD)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:RYAN
Last Name:FAVRE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:RYAN
Other - Last Name:WATERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 TWIN OAKS DR
Mailing Address - Street 2:
Mailing Address - City:SHILOH
Mailing Address - State:IL
Mailing Address - Zip Code:62221-4442
Mailing Address - Country:US
Mailing Address - Phone:870-391-6865
Mailing Address - Fax:
Practice Address - Street 1:4322 MCREE AVE APT 2W
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2253
Practice Address - Country:US
Practice Address - Phone:870-391-6865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-03
Last Update Date:2023-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016013025133V00000X
IL164007798133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered