Provider Demographics
NPI:1891220083
Name:WIMMER, AUDREY JANE (LMT)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:JANE
Last Name:WIMMER
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 N KILLINGSWORTH ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-2435
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:118 N KILLINGSWORTH ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97217-2435
Practice Address - Country:US
Practice Address - Phone:503-288-4454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-25
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR023192225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist