Healthcare Provider Details

I. General information

NPI: 1871839522
Provider Name (Legal Business Name): ASHLEY LYNN SNYDER RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ASHLEY DOMANSKI RD

II. Dates (important events)

Enumeration Date: 12/28/2012
Last Update Date: 12/24/2019
Certification Date: 12/24/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

419 S CORAL ST
KALKASKA MI
49646-2503
US

IV. Provider business mailing address

3898 VALE DR
TRAVERSE CITY MI
49686-2977
US

V. Phone/Fax

Practice location:
  • Phone: 231-258-3613
  • Fax:
Mailing address:
  • Phone: 616-366-5093
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: