Provider Demographics
NPI:1538703764
Name:BURGESS, ASHLEY D (CNP)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:D
Last Name:BURGESS
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:211 EDGEFIELD BLVD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-5801
Mailing Address - Country:US
Mailing Address - Phone:740-914-4178
Mailing Address - Fax:740-386-2640
Practice Address - Street 1:4135 TUSCARAWAS ST W
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-5463
Practice Address - Country:US
Practice Address - Phone:330-546-0913
Practice Address - Fax:330-546-0752
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-31
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.025699363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty