Provider Demographics
NPI:1659572501
Name:STOTT, AUDRA MARIE (LMP)
Entity Type:Individual
Prefix:MS
First Name:AUDRA
Middle Name:MARIE
Last Name:STOTT
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 1:30808 SE 384TH ST
Mailing Address - Street 2:
Mailing Address - City:ENUMCLAW
Mailing Address - State:WA
Mailing Address - Zip Code:98022-9697
Mailing Address - Country:US
Mailing Address - Phone:253-740-6800
Mailing Address - Fax:
Practice Address - Street 1:30808 SE 384TH ST
Practice Address - Street 2:
Practice Address - City:ENUMCLAW
Practice Address - State:WA
Practice Address - Zip Code:98022-9697
Practice Address - Country:US
Practice Address - Phone:253-740-6800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist