Healthcare Provider Details

I. General information

NPI: 1861846800
Provider Name (Legal Business Name): ASHLEY LAUREN FEDUSENKO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/15/2016
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

979 E 3RD ST STE A540A550
CHATTANOOGA TN
37403-2136
US

IV. Provider business mailing address

7887 EDEN CT
CHATTANOOGA TN
37421-4865
US

V. Phone/Fax

Practice location:
  • Phone: 423-778-2867
  • Fax: 423-778-8182
Mailing address:
  • Phone: 423-785-7637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number86562
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number60391
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207QH0002X
TaxonomyHospice and Palliative Medicine (Family Medicine) Physician
License Number60391
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: