Healthcare Provider Details

I. General information

NPI: 1285561381
Provider Name (Legal Business Name): AUDREY LEE WHITESIDE AU.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 05/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34800 BOB WILSON DR
SAN DIEGO CA
92134-1098
US

IV. Provider business mailing address

34800 BOB WILSON DR
SAN DIEGO CA
92134-1098
US

V. Phone/Fax

Practice location:
  • Phone: 616-260-9364
  • Fax:
Mailing address:
  • Phone: 616-260-9364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number323074497482
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: