Provider Demographics
NPI:1326755000
Name:BELLERUD, AUDREY INEZ (LMP)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:INEZ
Last Name:BELLERUD
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 1:6314 19TH ST W STE 11
Mailing Address - Street 2:
Mailing Address - City:FIRCREST
Mailing Address - State:WA
Mailing Address - Zip Code:98466-6223
Mailing Address - Country:US
Mailing Address - Phone:253-267-8188
Mailing Address - Fax:253-267-8187
Practice Address - Street 1:6314 19TH ST W STE 11
Practice Address - Street 2:
Practice Address - City:FIRCREST
Practice Address - State:WA
Practice Address - Zip Code:98466-6223
Practice Address - Country:US
Practice Address - Phone:253-267-8188
Practice Address - Fax:253-267-8187
Is Sole Proprietor?:No
Enumeration Date:2022-11-01
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60314041225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist