MEDICARE: ASHLEY NICOLE CREEDY

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	RN60311256	WA
2	363LF0000X	Family Nurse Practitioner	AP60704623	WA

General Provider Information

NPI Number	:	1619329034
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ASHLEY NICOLE CREEDY

Provider Business Mailing Address
First Line	:	2100 N WINROCK ST
Second Line	:
City	:	LIBERTY LAKE
State	:	WA
Zip	:	99019-5093
Country	:	US
Telephone Number	:	208-697-1421
Fax Number	:

Provider Business Practice Location Address
First Line	:	2100 N WINROCK ST
Second Line	:
City	:	LIBERTY LAKE
State	:	WA
Zip	:	99019-5093
Country	:	US
Telephone Number	:	208-697-1421
Fax Number	:

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

Provider Enumeration Date	:	07/09/2016
Last Update Date	:	12/06/2016

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