Provider Demographics
NPI:1902287766
Name:PROVENZO, ASHLEY ANN (FNP)
Entity Type:Individual
Prefix:MRS
First Name:ASHLEY
Middle Name:ANN
Last Name:PROVENZO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 CARDINAL LN
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:14072-1988
Mailing Address - Country:US
Mailing Address - Phone:585-317-9546
Mailing Address - Fax:
Practice Address - Street 1:462 GRIDER ST
Practice Address - Street 2:SUITE 15
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-3021
Practice Address - Country:US
Practice Address - Phone:716-898-3152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-17
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY339765363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily