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General NPI Number Information
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NPI Number | 1063065282
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Entity Type | Individual
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Provider Name | ASHLEY RENEE KELLOGG LMT, AMMP
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Gender | Female
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Dates
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Enumeration Date | 07/17/2019
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Last Update Date | 07/17/2019
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Provider Practice Location Address
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Address Line | 1650 W NORTHWEST HWY STE 103
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City | GRAPEVINE
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State | TX
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Zip | 76051-8122
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Country | US
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Telephone | 910-520-6236
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Fax |
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Provider Business Mailing Address
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Address Line | 6700 OLD STONE DR
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City | FORT WORTH
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State | TX
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Zip | 76137-2334
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Country | US
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Telephone | 910-520-6236
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MT116044
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License Number State | TX
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