Healthcare Provider Details

I. General information

NPI: 1053600924
Provider Name (Legal Business Name): AUDRA KRYSTELL MENDELSOHN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2011
Last Update Date: 02/10/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 BODIN CIR 60MDG/SGOC
TRAVIS AFB CA
94535-1809
US

IV. Provider business mailing address

101 BODIN CIR 60MDG/SGOC
TRAVIS AFB CA
94535-1809
US

V. Phone/Fax

Practice location:
  • Phone: 206-553-9317
  • Fax:
Mailing address:
  • Phone: 206-553-9317
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number01071564A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: