Provider Demographics
NPI:1083929376
Name:MISSILDINE, AUDREA H (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:AUDREA
Middle Name:H
Last Name:MISSILDINE
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1031 COUNTY ROAD 114
Mailing Address - Street 2:
Mailing Address - City:JACK
Mailing Address - State:AL
Mailing Address - Zip Code:36346-6264
Mailing Address - Country:US
Mailing Address - Phone:334-853-0177
Mailing Address - Fax:334-853-0178
Practice Address - Street 1:1031 COUNTY ROAD 114
Practice Address - Street 2:
Practice Address - City:JACK
Practice Address - State:AL
Practice Address - Zip Code:36346-6264
Practice Address - Country:US
Practice Address - Phone:334-853-0177
Practice Address - Fax:334-853-0178
Is Sole Proprietor?:No
Enumeration Date:2010-08-11
Last Update Date:2019-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-065276363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily