Provider Demographics
NPI:1063764447
Name:ASHLEY, KELLY M (CPNP)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:ASHLEY
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:364 HONEYSUCKLE ROAD
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-1140
Mailing Address - Country:US
Mailing Address - Phone:334-794-8656
Mailing Address - Fax:334-702-7047
Practice Address - Street 1:364 HONEYSUCKLE ROAD
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1140
Practice Address - Country:US
Practice Address - Phone:334-794-8656
Practice Address - Fax:334-702-7047
Is Sole Proprietor?:No
Enumeration Date:2012-10-09
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-093975363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-15001OtherBCBS OF AL
AL891005040Medicaid