Healthcare Provider Details

I. General information

NPI: 1609411784
Provider Name (Legal Business Name): ASHLEY MARIE TITCHENAL AGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2019
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 MEMORIAL DR STE 130
ALTON IL
62002-6704
US

IV. Provider business mailing address

PO BOX 959203
SAINT LOUIS MO
63195-9203
US

V. Phone/Fax

Practice location:
  • Phone: 618-463-7600
  • Fax: 618-463-7601
Mailing address:
  • Phone: 618-463-7600
  • Fax: 618-463-7601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209020653
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number2019040757
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: