Provider Demographics
NPI:1912751975
Name:BOUMGARDEN, ASHLEY ERIN
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:ERIN
Last Name:BOUMGARDEN
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 1:1022 S SCOVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60304-2128
Mailing Address - Country:US
Mailing Address - Phone:630-913-1195
Mailing Address - Fax:
Practice Address - Street 1:14 LAKE ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2606
Practice Address - Country:US
Practice Address - Phone:708-383-0113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-16
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209030519363LF0000X
IL041462308163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse