1609848142 NPI number — MISS AUDREY C STANLEY MS, LAT, ATC

Table of content: MISS AUDREY C STANLEY MS, LAT, ATC (NPI 1609848142)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609848142 NPI number — MISS AUDREY C STANLEY MS, LAT, ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
STANLEY
Provider First Name:
AUDREY
Provider Middle Name:
C
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
MS, LAT, ATC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1609848142
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/26/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
121 PRIDEMORE ST
Provider Second Line Business Mailing Address:
APT 6
Provider Business Mailing Address City Name:
CHURCH HILL
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37642-3871
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-571-2220
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1050 VOLUNTEER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHURCH HILL
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37642-4435
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-357-3641
Provider Business Practice Location Address Fax Number:
423-357-6694
Provider Enumeration Date:
02/07/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  0000001067 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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