Healthcare Provider Details

I. General information

NPI: 1528610722
Provider Name (Legal Business Name): ASHLEY DAWN HARRIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2019
Last Update Date: 07/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11325 PRIVATE DRIVE 2111
ROLLA MO
65401-8279
US

IV. Provider business mailing address

11325 PRIVATE DRIVE 2111
ROLLA MO
65401-8279
US

V. Phone/Fax

Practice location:
  • Phone: 573-578-6769
  • Fax:
Mailing address:
  • Phone: 573-578-6769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2016037341
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: