Provider Demographics
NPI:1083628986
Name:ST. JOHN, AUDREY LOU (MMP, CNMT, LMT)
Entity Type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:LOU
Last Name:ST. JOHN
Suffix:
Gender:F
Credentials:MMP, CNMT, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 CARNATION CT
Mailing Address - Street 2:
Mailing Address - City:KINGSLAND
Mailing Address - State:GA
Mailing Address - Zip Code:31548-5606
Mailing Address - Country:US
Mailing Address - Phone:912-227-4474
Mailing Address - Fax:
Practice Address - Street 1:1204 HOSPITALITY AVE
Practice Address - Street 2:SUITE K
Practice Address - City:KINGSLAND
Practice Address - State:GA
Practice Address - Zip Code:31548-6810
Practice Address - Country:US
Practice Address - Phone:912-510-0264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 44253174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist