Healthcare Provider Details

I. General information

NPI: 1063732634
Provider Name (Legal Business Name): ASHLEY KAISER RICKEY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2010
Last Update Date: 10/25/2020
Certification Date: 09/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2827 LYNDHURST AVE STE 203
WINSTON SALEM NC
27103-4145
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 336-794-8624
  • Fax: 336-231-8845
Mailing address:
  • Phone: 336-794-8624
  • Fax: 336-231-8845

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberLL32642
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2015-00330
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number2015-00330
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: