Provider Demographics
NPI:1942527288
Name:STEWART, AUDREY L (LAC)
Entity Type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:L
Last Name:STEWART
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1460
Mailing Address - Street 2:
Mailing Address - City:MATHEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23109-1460
Mailing Address - Country:US
Mailing Address - Phone:804-725-9001
Mailing Address - Fax:804-725-9005
Practice Address - Street 1:28 CHURCH STREET
Practice Address - Street 2:
Practice Address - City:MATHEWS
Practice Address - State:VA
Practice Address - Zip Code:23109-1460
Practice Address - Country:US
Practice Address - Phone:804-725-9001
Practice Address - Fax:804-725-9005
Is Sole Proprietor?:No
Enumeration Date:2010-04-27
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0121000563225500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225500000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/Technologist