Provider Demographics
NPI:1821394958
Name:LUNG, AUDREY JANE (PTA)
Entity type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:JANE
Last Name:LUNG
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:MISS
Other - First Name:AUDREY
Other - Middle Name:JANE
Other - Last Name:SHARP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:5659 STADIUM DR STE A
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-1932
Mailing Address - Country:US
Mailing Address - Phone:269-372-0436
Mailing Address - Fax:269-372-0483
Practice Address - Street 1:5659 STADIUM DR STE A
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-1932
Practice Address - Country:US
Practice Address - Phone:269-372-0436
Practice Address - Fax:269-372-0483
Is Sole Proprietor?:No
Enumeration Date:2011-02-08
Last Update Date:2011-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502001388225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant