Healthcare Provider Details

I. General information

NPI: 1467894501
Provider Name (Legal Business Name): ASHLEYRAE DONALD D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2013
Last Update Date: 08/16/2021
Certification Date: 08/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2812 54TH AVE S
ST PETERSBURG FL
33712-4610
US

IV. Provider business mailing address

2812 54TH AVE S
ST PETERSBURG FL
33712-4610
US

V. Phone/Fax

Practice location:
  • Phone: 727-867-8641
  • Fax: 727-867-6795
Mailing address:
  • Phone: 727-867-8641
  • Fax: 727-867-6795

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberOS16882
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number074016
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: