Provider Demographics
NPI:1730570094
Name:AVERY, ASHLEY NICOLE
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:NICOLE
Last Name:AVERY
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:PO BOX 1473
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73402-1473
Mailing Address - Country:US
Mailing Address - Phone:580-677-5085
Mailing Address - Fax:
Practice Address - Street 1:1310 SUMMER RD
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-8352
Practice Address - Country:US
Practice Address - Phone:580-677-5085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-09
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator