Provider Demographics
NPI:1982343281
Name:VIDRINE, AUDREY JENNINGS (LCOTA)
Entity Type:Individual
Prefix:MRS
First Name:AUDREY
Middle Name:JENNINGS
Last Name:VIDRINE
Suffix:
Gender:F
Credentials:LCOTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 EISENHOWER DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-6812
Mailing Address - Country:US
Mailing Address - Phone:318-464-0505
Mailing Address - Fax:
Practice Address - Street 1:3001 ARMAND ST STE I
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-3761
Practice Address - Country:US
Practice Address - Phone:318-302-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-03
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA321501224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA321501OtherLSBME