Provider Demographics
NPI:1740703750
Name:BERNING, AUDRA K
Entity type:Individual
Prefix:
First Name:AUDRA
Middle Name:K
Last Name:BERNING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3035 NE MARTIN LUTHER KING JR BLVD APT 203
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212-3094
Mailing Address - Country:US
Mailing Address - Phone:505-819-8305
Mailing Address - Fax:
Practice Address - Street 1:2122 NW QUIMBY
Practice Address - Street 2:ROOT WHOLE BODY
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210
Practice Address - Country:US
Practice Address - Phone:503-292-7668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-21
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR22556225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR22556OtherBOARD OF MASSAGE THERAPISTS