Provider Demographics
NPI:1528610722
Name:HARRIS, ASHLEY DAWN
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:DAWN
Last Name:HARRIS
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 1:11325 PRIVATE DRIVE 2111
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-8279
Mailing Address - Country:US
Mailing Address - Phone:573-578-6769
Mailing Address - Fax:
Practice Address - Street 1:11325 PRIVATE DRIVE 2111
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-8279
Practice Address - Country:US
Practice Address - Phone:573-578-6769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-09
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016037341225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty