Basic Information
Provider Information | |||||||||
NPI: | 1891445961 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PAX | ||||||||
FirstName: | ASHLEE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RDN, LD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BESGROVE | ||||||||
OtherFirstName: | ASHLEE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RDN, LD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1100 REID PARKWAY | ||||||||
Address2: | MEDICAL STAFF SERVICES | ||||||||
City: | RICHMOND | ||||||||
State: | IN | ||||||||
PostalCode: | 473741157 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6593588027 | ||||||||
FaxNumber: | 7659833219 | ||||||||
Practice Location | |||||||||
Address1: | 1050 REID PKWY STE 305 | ||||||||
Address2: |   | ||||||||
City: | RICHMOND | ||||||||
State: | IN | ||||||||
PostalCode: | 473741159 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7659833423 | ||||||||
FaxNumber: | 7659837924 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/24/2022 | ||||||||
LastUpdateDate: | 08/03/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/25/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 37002511A | IN | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
No ID Information.