Healthcare Provider Details

I. General information

NPI: 1508291261
Provider Name (Legal Business Name): ASHLEY ELIZABETH TEAGUE L.AC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ASHLEY ELIZABETH ITTERLY L.AC

II. Dates (important events)

Enumeration Date: 09/12/2013
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 SUNSET BLVD
WADING RIVER NY
11792-1051
US

IV. Provider business mailing address

164 SUNSET BLVD
WADING RIVER NY
11792-1051
US

V. Phone/Fax

Practice location:
  • Phone: 631-681-9109
  • Fax:
Mailing address:
  • Phone: 631-681-9109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number005046
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: