=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376123893
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ASHLEY FAMILLION
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2021
-----------------------------------------------------
Last Update Date | 07/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 714 N MICHIGAN ST
-----------------------------------------------------
City | SOUTH BEND
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46601-1035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-647-7477
-----------------------------------------------------
Fax | 574-647-3655
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3245 HEALTH DR STE 100
-----------------------------------------------------
City | GRANGER
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46530-1380
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-647-1840
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | LL86415
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 01093798A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------