Healthcare Provider Details

I. General information

NPI: 1912449653
Provider Name (Legal Business Name): ASHLEY WYBENGA M.S
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/11/2016
Last Update Date: 11/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

729 OTTILLIA ST SE
GRAND RAPIDS MI
49507-3241
US

IV. Provider business mailing address

729 OTTILLIA ST SE
GRAND RAPIDS MI
49507-3241
US

V. Phone/Fax

Practice location:
  • Phone: 206-696-8684
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: