Basic Information
Provider Information | |||||||||
NPI: | 1962931410 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MANN | ||||||||
FirstName: | ASHLEY | ||||||||
MiddleName: | CANNON | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 301 BROWN SPRINGS RD | ||||||||
Address2: |   | ||||||||
City: | MONTGOMERY | ||||||||
State: | AL | ||||||||
PostalCode: | 361177005 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3342734159 | ||||||||
FaxNumber: | 3342734556 | ||||||||
Practice Location | |||||||||
Address1: | 4145 CARMICHAEL ROAD | ||||||||
Address2: |   | ||||||||
City: | MONTGOMERY | ||||||||
State: | AL | ||||||||
PostalCode: | 36106 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3342737000 | ||||||||
FaxNumber: | 3342732228 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/08/2017 | ||||||||
LastUpdateDate: | 10/30/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 1-122663 | AL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
ID | Type | State | Issuer | Description | 511-94956 | 01 | AL | BCBS | OTHER | 511-94957 | 01 | AL | BCBS | OTHER | 510G700564 | 01 | AL | MEDICARE | OTHER | 203893 | 05 | AL |   | MEDICAID | 4766889 | 01 | AL | AETNA | OTHER | Z98667 | 01 | AL | VIVA | OTHER |