Provider Demographics
NPI:1699149724
Name:PETERSON, ASHLEY MEGAN (LMT)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MEGAN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:MEGAN
Other - Last Name:AMELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1577 ROBERTS DR
Mailing Address - Street 2:STE 320
Mailing Address - City:JACKSONVILLE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32250-3264
Mailing Address - Country:US
Mailing Address - Phone:904-247-3324
Mailing Address - Fax:904-247-3926
Practice Address - Street 1:1577 ROBERTS DR
Practice Address - Street 2:STE 320
Practice Address - City:JACKSONVILLE BEACH
Practice Address - State:FL
Practice Address - Zip Code:32250-3264
Practice Address - Country:US
Practice Address - Phone:904-247-3324
Practice Address - Fax:904-247-3926
Is Sole Proprietor?:No
Enumeration Date:2015-12-01
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA80255225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist