Provider Demographics
NPI:1821500901
Name:PUTMAN, AUDRA E (ARNP)
Entity Type:Individual
Prefix:MS
First Name:AUDRA
Middle Name:E
Last Name:PUTMAN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 W UNDERWOOD ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32806-1110
Mailing Address - Country:US
Mailing Address - Phone:321-843-5270
Mailing Address - Fax:321-843-5177
Practice Address - Street 1:86 W UNDERWOOD ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1110
Practice Address - Country:US
Practice Address - Phone:321-843-5270
Practice Address - Fax:321-843-5177
Is Sole Proprietor?:No
Enumeration Date:2017-10-30
Last Update Date:2018-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9457524363LA2100X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022835000Medicaid