Healthcare Provider Details

I. General information

NPI: 1811328099
Provider Name (Legal Business Name): ASHLEY WAMBOLT MCCORMICK FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ASHLEY WAMBOLT CROWLEY FNP-C

II. Dates (important events)

Enumeration Date: 12/12/2013
Last Update Date: 02/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1706 S. JEFFERSON
PERRY FL
32348
US

IV. Provider business mailing address

1706 S. JEFFERSON
PERRY FL
32348
US

V. Phone/Fax

Practice location:
  • Phone: 850-838-8636
  • Fax: 850-838-3614
Mailing address:
  • Phone: 850-838-8636
  • Fax: 850-838-3614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9276244
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9276244
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: