Provider Demographics
NPI:1154981868
Name:BURNETT, ASHLEY MICHELLE
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MICHELLE
Last Name:BURNETT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17700 W CAPITOL DR
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-2006
Mailing Address - Country:US
Mailing Address - Phone:262-781-3083
Mailing Address - Fax:262-781-3080
Practice Address - Street 1:17700 W CAPITOL DR
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-2006
Practice Address - Country:US
Practice Address - Phone:262-781-3083
Practice Address - Fax:262-781-3080
Is Sole Proprietor?:No
Enumeration Date:2019-06-14
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL15188225XP0019X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation