Healthcare Provider Details

I. General information

NPI: 1639496565
Provider Name (Legal Business Name): ASHLEY R VRECENAK P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2010
Last Update Date: 04/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 W STATE ROAD 434 SUITE 210
LONGWOOD FL
32750-4981
US

IV. Provider business mailing address

515 W STATE ROAD 434 SUITE 210
LONGWOOD FL
32750-4981
US

V. Phone/Fax

Practice location:
  • Phone: 407-332-8080
  • Fax: 407-260-0602
Mailing address:
  • Phone: 407-332-8080
  • Fax: 407-260-0602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9105430
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: