Healthcare Provider Details

I. General information

NPI: 1760008833
Provider Name (Legal Business Name): ASHLEY BERTAUT STICKMAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2020
Last Update Date: 10/01/2020
Certification Date: 10/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1514 JEFFERSON HWY
JEFFERSON LA
70121-2429
US

IV. Provider business mailing address

1514 JEFFERSON HWY
NEW ORLEANS LA
70121-2429
US

V. Phone/Fax

Practice location:
  • Phone: 504-703-5328
  • Fax:
Mailing address:
  • Phone: 504-703-5328
  • Fax: 504-842-3689

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1301X
TaxonomyOncology Nutrition Registered Dietitian
License Number2738
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: