Provider Demographics
NPI:1831446137
Name:HAWKINS, AUDRA MARLO (PTA)
Entity type:Individual
Prefix:MRS
First Name:AUDRA
Middle Name:MARLO
Last Name:HAWKINS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:AUDRA
Other - Middle Name:MARLO
Other - Last Name:CILC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:325 E H ST
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-4760
Mailing Address - Country:US
Mailing Address - Phone:800-215-8262
Mailing Address - Fax:906-779-3187
Practice Address - Street 1:325 E H ST
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-4760
Practice Address - Country:US
Practice Address - Phone:800-215-8262
Practice Address - Fax:906-779-3187
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5502001780225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant