Provider Demographics
NPI:1861817272
Name:OWEN, AUDREY GRIFFIN (NP-C)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:GRIFFIN
Last Name:OWEN
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:LEE
Other - Last Name:GRIFFIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1825 MARTHA BERRY BLVD NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1625
Mailing Address - Country:US
Mailing Address - Phone:706-295-5331
Mailing Address - Fax:
Practice Address - Street 1:504 REDMOND RD NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1416
Practice Address - Country:US
Practice Address - Phone:706-235-3855
Practice Address - Fax:706-290-2710
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-21
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN200411363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN200411OtherSTATE LICENSE