Provider Demographics
NPI:1073590063
Name:AUDLEY, SANDRA LYNN (MS, RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:LYNN
Last Name:AUDLEY
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4514 BADER AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44109-5266
Mailing Address - Country:US
Mailing Address - Phone:216-832-1311
Mailing Address - Fax:216-741-8705
Practice Address - Street 1:4514 BADER AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44109-5266
Practice Address - Country:US
Practice Address - Phone:216-832-1311
Practice Address - Fax:216-741-8705
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4532133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000379531OtherANTHEM BLUE CROSS/SHIELD
OH000000379531OtherANTHEM BLUE CROSS/SHIELD