Provider Demographics
NPI:1487820049
Name:HAYDEN, AUDIRA MARIE
Entity Type:Individual
Prefix:
First Name:AUDIRA
Middle Name:MARIE
Last Name:HAYDEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AUDRIA
Other - Middle Name:MARIE
Other - Last Name:SIMONIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1406 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-8511
Mailing Address - Country:US
Mailing Address - Phone:541-910-4384
Mailing Address - Fax:
Practice Address - Street 1:1406 CHERRY ST
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850
Practice Address - Country:US
Practice Address - Phone:541-910-4384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-05
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR14633174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist