Provider Demographics
NPI:1164284857
Name:GREGORY, AUDREY MICHELLE
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:MICHELLE
Last Name:GREGORY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2780 ELITE LN APT 201
Mailing Address - Street 2:
Mailing Address - City:WEST LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47906-5391
Mailing Address - Country:US
Mailing Address - Phone:219-629-9002
Mailing Address - Fax:
Practice Address - Street 1:2780 ELITE LN APT 201
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-5391
Practice Address - Country:US
Practice Address - Phone:219-629-9002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN4032-3283146N00000X
2255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, BasicGroup - Multi-Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer