Provider Demographics
NPI:1316487721
Name:WILSON, ASHLEY NICOLE (RD)
Entity type:Individual
Prefix:MISS
First Name:ASHLEY
Middle Name:NICOLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5955 ZEAMER AVE
Mailing Address - Street 2:673D MDG
Mailing Address - City:JBER
Mailing Address - State:AK
Mailing Address - Zip Code:99506-3702
Mailing Address - Country:US
Mailing Address - Phone:907-552-8890
Mailing Address - Fax:
Practice Address - Street 1:5955 ZEAMER AVE
Practice Address - Street 2:673D MDG
Practice Address - City:JBER
Practice Address - State:AK
Practice Address - Zip Code:99506-3702
Practice Address - Country:US
Practice Address - Phone:907-552-8890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-03
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86033504133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered