Healthcare Provider Details

I. General information

NPI: 1396375366
Provider Name (Legal Business Name): ASHLEY VICTORIA MARR CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2020
Last Update Date: 03/09/2021
Certification Date: 03/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 PAGE AVE
JACKSON MI
49201-2419
US

IV. Provider business mailing address

4054 MCKENNA DR
ADRIAN MI
49221-9033
US

V. Phone/Fax

Practice location:
  • Phone: 517-205-0500
  • Fax:
Mailing address:
  • Phone: 517-673-1476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number4704283616
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: