Provider Demographics
NPI:1831432392
Name:LAFATA, ASHLEY NICOLE
Entity type:Individual
Prefix:MISS
First Name:ASHLEY
Middle Name:NICOLE
Last Name:LAFATA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 PENN SQUARE EAST
Mailing Address - Street 2:9TH FLOOR NORTH TOWER
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107
Mailing Address - Country:US
Mailing Address - Phone:267-425-9200
Mailing Address - Fax:267-425-9299
Practice Address - Street 1:555 N DUKE ST
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17602
Practice Address - Country:US
Practice Address - Phone:717-544-5511
Practice Address - Fax:717-544-5333
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-03
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD462061208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1033472890001Medicaid