Healthcare Provider Details

I. General information

NPI: 1255895975
Provider Name (Legal Business Name): ASHLEY STANCZAK WILLIS PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2019
Last Update Date: 01/30/2024
Certification Date: 01/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1226 DANTIGNAC ST
AUGUSTA GA
30901-2788
US

IV. Provider business mailing address

1226 DANTIGNAC ST
AUGUSTA GA
30901-2788
US

V. Phone/Fax

Practice location:
  • Phone: 706-922-0600
  • Fax:
Mailing address:
  • Phone: 404-520-1475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN241647
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: