Provider Demographics
NPI:1780362202
Name:MISSILDINE, AUDREY
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:MISSILDINE
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 1:1020 GERALD AVE
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-4238
Mailing Address - Country:US
Mailing Address - Phone:360-480-2972
Mailing Address - Fax:
Practice Address - Street 1:32 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59812-0004
Practice Address - Country:US
Practice Address - Phone:406-243-0211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-05
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer