Provider Demographics
NPI:1104593425
Name:KINGMAN, AUDREY CHARLOTTE (CNM)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:CHARLOTTE
Last Name:KINGMAN
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 ARCH ST APT 805
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19103-1538
Mailing Address - Country:US
Mailing Address - Phone:607-379-2799
Mailing Address - Fax:
Practice Address - Street 1:2500 ENGLISH CREEK AVE STE 1000
Practice Address - Street 2:
Practice Address - City:EGG HARBOR TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08234-5508
Practice Address - Country:US
Practice Address - Phone:609-677-7211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-25
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25ME00075601367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty