MEDICARE: ASHLEY BROOKE HACKWORTH MEDICAL STUDENT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1063164622
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ASHLEY BROOKE HACKWORTH MEDICAL STUDENT

Provider Business Mailing Address
First Line	:	1348 SW 2ND CT
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33312-7593
Country	:	US
Telephone Number	:
Fax Number	:	636-357-6719

Provider Business Practice Location Address
First Line	:	1348 SW 2ND CT
Second Line	:
City	:	FORT LAUDERDALE
State	:	FL
Zip	:	33312-7593
Country	:	US
Telephone Number	:	636-357-6719
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/24/2022
Last Update Date	:	01/24/2022

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