Healthcare Provider Details

I. General information

NPI: 1780427005
Provider Name (Legal Business Name): ASHLEY RODRIGUEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2024
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 NE CRESCENT AVE
PEORIA IL
61606-1901
US

IV. Provider business mailing address

112 NE CRESCENT AVE
PEORIA IL
61606-1901
US

V. Phone/Fax

Practice location:
  • Phone: 309-672-4670
  • Fax:
Mailing address:
  • Phone: 309-672-4670
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085010770
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: