Healthcare Provider Details

I. General information

NPI: 1801581038
Provider Name (Legal Business Name): ASHLEY KOFF RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2023
Last Update Date: 04/05/2023
Certification Date: 04/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 WASHINGTON ST UNIT 213
CAMDEN ME
04843-1577
US

IV. Provider business mailing address

40 WASHINGTON ST UNIT 213
CAMDEN ME
04843-1577
US

V. Phone/Fax

Practice location:
  • Phone: 323-251-7537
  • Fax:
Mailing address:
  • Phone: 323-251-7537
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number916887
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: