Healthcare Provider Details

I. General information

NPI: 1376142943
Provider Name (Legal Business Name): ASHLEY B CHITTENDEN CPNP-AC/PC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2020
Last Update Date: 09/22/2025
Certification Date: 09/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3480 AVIS LN
SOUTHAVEN MS
38672-2010
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX 635
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 716-949-2677
  • Fax:
Mailing address:
  • Phone: 585-275-2981
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number383642
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number12180639
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: