Provider Demographics
NPI:1174681167
Name:MARSHALL, AUDREY E (LMP)
Entity Type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:E
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2411 PACIFIC AVE SE FL 1
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98501-2048
Mailing Address - Country:US
Mailing Address - Phone:360-485-2237
Mailing Address - Fax:815-301-3767
Practice Address - Street 1:2411 PACIFIC AVE SE FL 1
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98501-2048
Practice Address - Country:US
Practice Address - Phone:360-485-2237
Practice Address - Fax:815-301-3767
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2013-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA#12952174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8381MAOtherREGENCE BLUE SHIELD
WA132940OtherL&I NUMBER
WA8382MAOtherREGENCE BLUE SHIELD