Provider Demographics
NPI:1659911774
Name:ATKINS, AUDRETTA DEANNE
Entity Type:Individual
Prefix:
First Name:AUDRETTA
Middle Name:DEANNE
Last Name:ATKINS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7883 SHAKER CT
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-5708
Mailing Address - Country:US
Mailing Address - Phone:260-573-7728
Mailing Address - Fax:855-710-7995
Practice Address - Street 1:7883 SHAKER CT
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-5708
Practice Address - Country:US
Practice Address - Phone:260-573-7728
Practice Address - Fax:855-710-7995
Is Sole Proprietor?:No
Enumeration Date:2020-01-07
Last Update Date:2020-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0500229390172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver