Provider Demographics
NPI:1669122529
Name:MOORE, ASHLEY (AESTHETICIAN)
Entity type:Individual
Prefix:MS
First Name:ASHLEY
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:AESTHETICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10520 N BAEHR RD STE M
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-6701
Mailing Address - Country:US
Mailing Address - Phone:262-416-8385
Mailing Address - Fax:
Practice Address - Street 1:10520 N BAEHR RD STE M
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-6701
Practice Address - Country:US
Practice Address - Phone:262-416-8385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-24
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier