1164799649 NPI number — MRS. ASHLEY SHAVON WICKWIRE LMT

Table of content: MRS. ASHLEY SHAVON WICKWIRE LMT (NPI 1164799649)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164799649 NPI number — MRS. ASHLEY SHAVON WICKWIRE LMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WICKWIRE
Provider First Name:
ASHLEY
Provider Middle Name:
SHAVON
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LMT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCCARRELL
Provider Other First Name:
ASHLEY
Provider Other Middle Name:
SHAVON
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1164799649
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/28/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10905 CLAREMONT AVE NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALBUQUERQUE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87112-1606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-712-0122
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10905 CLAREMONT AVE NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALBUQUERQUE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87112-1606
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-712-0122
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/28/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171W00000X , with the licence number:  7130 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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