MEDICARE: MISS ASHLIE STWALLEY

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	2255A2300X	Athletic Trainer
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1528603321
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS ASHLIE STWALLEY

Provider Business Mailing Address
First Line	:	1008 COTTONWOOD AVE
Second Line	:
City	:	LAS ANIMAS
State	:	CO
Zip	:	81054-1819
Country	:	US
Telephone Number	:	719-980-2026
Fax Number	:

Provider Business Practice Location Address
First Line	:	1008 COTTONWOOD AVE
Second Line	:
City	:	LAS ANIMAS
State	:	CO
Zip	:	81054-1819
Country	:	US
Telephone Number	:	719-980-2026
Fax Number	:

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

Provider Enumeration Date	:	11/15/2019
Last Update Date	:	11/15/2019

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Directions to “ MISS ASHLIE STWALLEY ” Practice Location

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