Healthcare Provider Details

I. General information

NPI: 1225297534
Provider Name (Legal Business Name): ASHLEY JO HEINTZELMAN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2008
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47601 GRAND RIVER AVE
NOVI MI
48374-1233
US

IV. Provider business mailing address

57323 HIDDEN TIMBERS DR
SOUTH LYON MI
48178-8701
US

V. Phone/Fax

Practice location:
  • Phone: 248-465-4100
  • Fax:
Mailing address:
  • Phone: 586-871-8044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601005247
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: