Healthcare Provider Details

I. General information

NPI: 1306143268
Provider Name (Legal Business Name): ASHLEY NICOLE DOUGVILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ASHLEY FLAMENT

II. Dates (important events)

Enumeration Date: 02/11/2011
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13250 WASHINGTON AVE
MOUNT PLEASANT WI
53177-1516
US

IV. Provider business mailing address

3049 MOMENTUM PL
CHICAGO IL
60689-1957
US

V. Phone/Fax

Practice location:
  • Phone: 262-799-8330
  • Fax:
Mailing address:
  • Phone: 262-657-0222
  • Fax: 262-657-7190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number11656-24
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070-018760
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: