Provider Demographics
NPI:1720345184
Name:ELLISON, ASHLEY GARNER (MD)
Entity Type:Individual
Prefix:DR
First Name:ASHLEY
Middle Name:GARNER
Last Name:ELLISON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:ASHLEY
Other - Middle Name:MARIE
Other - Last Name:GARNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:100 KIMEL FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:336-716-1331
Mailing Address - Fax:336-716-3202
Practice Address - Street 1:3333 BROOKVIEW HILLS BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-5661
Practice Address - Country:US
Practice Address - Phone:336-765-5250
Practice Address - Fax:336-659-0953
Is Sole Proprietor?:No
Enumeration Date:2012-04-23
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.2067532084P0800X
NC2018-023642084P0800X, 207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2193066Medicaid
MS00580093Medicaid
LA440212YH3UMedicare PIN