Provider Demographics
NPI:1700610706
Name:MAIETTA, ASHLEY GRACE
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:GRACE
Last Name:MAIETTA
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 1:207 CHARTWELL CT
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29588-7273
Mailing Address - Country:US
Mailing Address - Phone:843-333-2816
Mailing Address - Fax:
Practice Address - Street 1:207 CHARTWELL CT
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-7273
Practice Address - Country:US
Practice Address - Phone:843-333-2816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-30
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC29298363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology