Provider Demographics
NPI:1417346511
Name:KINGZETT, AUDRIE (CPM, LDEM)
Entity Type:Individual
Prefix:
First Name:AUDRIE
Middle Name:
Last Name:KINGZETT
Suffix:
Gender:F
Credentials:CPM, LDEM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3000 DELTA WATERS RD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-5840
Mailing Address - Country:US
Mailing Address - Phone:541-261-3950
Mailing Address - Fax:541-245-0417
Practice Address - Street 1:400 CRATER LAKE AVE
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-6808
Practice Address - Country:US
Practice Address - Phone:541-772-2291
Practice Address - Fax:541-245-0417
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-13
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDEM-LD10166074176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife