Provider Demographics
NPI:1336839596
Name:SWAN, ASHLEY (NP)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:SWAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:262-275-2101
Mailing Address - Fax:262-275-0752
Practice Address - Street 1:525 KENOSHA ST STE A
Practice Address - Street 2:
Practice Address - City:WALWORTH
Practice Address - State:WI
Practice Address - Zip Code:53184-9512
Practice Address - Country:US
Practice Address - Phone:262-275-2101
Practice Address - Fax:262-275-0752
Is Sole Proprietor?:No
Enumeration Date:2023-05-11
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI242029363L00000X
WI13922363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI100238163Medicaid