=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528473311
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ASHLEY STEFFENS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/30/2014
-----------------------------------------------------
Last Update Date | 01/06/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5401 N KNOXVILLE AVE
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61614-5098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 93-691-2903
-----------------------------------------------------
Fax | 309-691-2909
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5401 N KNOXVILLE AVE STE 115
-----------------------------------------------------
City | PEORIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61614-5095
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 309-691-2903
-----------------------------------------------------
Fax | 93-691-2909
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 036145285
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------