=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720438864
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ASHLEY MARSHALL MSC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2016
-----------------------------------------------------
Last Update Date | 06/20/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 910 NW 16TH ST SUITE 200
-----------------------------------------------------
City | FRUITLAND
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83619-2265
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-452-8060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1059 W PINE AVE APT 4
-----------------------------------------------------
City | MERIDIAN
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83642-8324
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-283-6502
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | PT-4701
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------