Provider Demographics
NPI:1609346386
Name:SHUTACK, ASHLEY ROSE (ATC)
Entity type:Individual
Prefix:
First Name:ASHLEY
Middle Name:ROSE
Last Name:SHUTACK
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 BREE DR
Mailing Address - Street 2:
Mailing Address - City:HAMILTON SQUARE
Mailing Address - State:NJ
Mailing Address - Zip Code:08690-1502
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 BREE DR
Practice Address - Street 2:
Practice Address - City:HAMILTON SQUARE
Practice Address - State:NJ
Practice Address - Zip Code:08690-1502
Practice Address - Country:US
Practice Address - Phone:609-529-3454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-26
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJNJX3HZN34669260OtherHORIZON BLUE CROSS BLUE SHIELD