Provider Demographics
NPI:1699383364
Name:NILSSEN, ASHLEY MARIE
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:MARIE
Last Name:NILSSEN
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 1:340 E 13TH ST
Mailing Address - Street 2:
Mailing Address - City:ZUMBROTA
Mailing Address - State:MN
Mailing Address - Zip Code:55992-1682
Mailing Address - Country:US
Mailing Address - Phone:507-358-8672
Mailing Address - Fax:
Practice Address - Street 1:350 22ND ST
Practice Address - Street 2:
Practice Address - City:ZUMBROTA
Practice Address - State:MN
Practice Address - Zip Code:55992-5201
Practice Address - Country:US
Practice Address - Phone:507-732-5346
Practice Address - Fax:507-237-6918
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-20
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MND144431223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty