Provider Demographics
NPI:1801263330
Name:SQUIRE, AUDREY ELIZABETH (MS LCGC)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:ELIZABETH
Last Name:SQUIRE
Suffix:
Gender:F
Credentials:MS LCGC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 OGLETOWN STANTON RD
Mailing Address - Street 2:SUITE 2200
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4701 OGLETOWN STANTON RD
Practice Address - Street 2:SUITE 2200
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2055
Practice Address - Country:US
Practice Address - Phone:302-623-4593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-01
Last Update Date:2015-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAGC000201170300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes170300000XOther Service ProvidersGenetic Counselor, MS