Provider Demographics
NPI:1053984401
Name:SIDELL, ASHLEY (LAC)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:SIDELL
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4369 LYNX PAW TRL
Mailing Address - Street 2:
Mailing Address - City:VALRICO
Mailing Address - State:FL
Mailing Address - Zip Code:33596-7426
Mailing Address - Country:US
Mailing Address - Phone:813-708-9990
Mailing Address - Fax:
Practice Address - Street 1:4369 LYNX PAW TRL
Practice Address - Street 2:
Practice Address - City:VALRICO
Practice Address - State:FL
Practice Address - Zip Code:33596-7426
Practice Address - Country:US
Practice Address - Phone:813-708-9990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-22
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP4256171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist