Healthcare Provider Details

I. General information

NPI: 1780230631
Provider Name (Legal Business Name): ASHLEY MOAB GEFFRARD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2019
Last Update Date: 08/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18323 ARCADE AVE
SAINT ALBANS NY
11412-1501
US

IV. Provider business mailing address

18323 ARCADE AVE
SAINT ALBANS NY
11412-1501
US

V. Phone/Fax

Practice location:
  • Phone: 516-884-0445
  • Fax:
Mailing address:
  • Phone: 516-884-0445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: