Provider Demographics
NPI:1336409267
Name:MCKILLIP, ASHLEY ZICCARELLI (MED, CCC-SLP)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:ZICCARELLI
Last Name:MCKILLIP
Suffix:
Gender:F
Credentials:MED, CCC-SLP
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:
Other - Last Name:ZICCARELLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MED, CCC-SLP
Mailing Address - Street 1:273 PALISADE DR
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32092-1138
Mailing Address - Country:US
Mailing Address - Phone:716-864-8192
Mailing Address - Fax:
Practice Address - Street 1:12276 SAN JOSE BLVD STE 508
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-8618
Practice Address - Country:US
Practice Address - Phone:904-886-3228
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-25
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSA11878235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist