Provider Demographics
NPI:1861016107
Name:GARNSEY, AUDREY LEE
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:LEE
Last Name:GARNSEY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:LEE
Other - Last Name:BRACKEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9481 E KIMBALL RD
Mailing Address - Street 2:
Mailing Address - City:PEWAMO
Mailing Address - State:MI
Mailing Address - Zip Code:48873-9726
Mailing Address - Country:US
Mailing Address - Phone:810-404-1983
Mailing Address - Fax:
Practice Address - Street 1:10599 E BOYER RD
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:MI
Practice Address - Zip Code:48811
Practice Address - Country:US
Practice Address - Phone:989-584-3941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-02
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601010620363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program