Healthcare Provider Details

I. General information

NPI: 1194130286
Provider Name (Legal Business Name): ASHLEY NOEGEL O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2014
Last Update Date: 05/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 TUSCAN WAY STE 104
ST AUGUSTINE FL
32092-1851
US

IV. Provider business mailing address

52 TUSCAN WAY STE 202-103
ST AUGUSTINE FL
32092-1850
US

V. Phone/Fax

Practice location:
  • Phone: 904-547-2691
  • Fax:
Mailing address:
  • Phone: 904-547-2691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC4914
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: