Provider Demographics
NPI:1942301973
Name:KALBACH, AUDREY A (FNP)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:A
Last Name:KALBACH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:A
Other - Last Name:LUTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 10414
Mailing Address - Street 2:
Mailing Address - City:LARGO
Mailing Address - State:FL
Mailing Address - Zip Code:33773-0414
Mailing Address - Country:US
Mailing Address - Phone:800-632-6074
Mailing Address - Fax:
Practice Address - Street 1:450 COLLEGE ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:TN
Practice Address - Zip Code:37821-3752
Practice Address - Country:US
Practice Address - Phone:800-632-6074
Practice Address - Fax:866-341-7509
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000006141163WP0809X
TNRN0000072908363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4100522OtherBCBS
TN36488471Medicaid
TNP00229948OtherRAILROAD MEDICARE
TN36488471Medicaid
TNQ37959Medicare UPIN