Healthcare Provider Details

I. General information

NPI: 1477468189
Provider Name (Legal Business Name): AUDRA MARTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/17/2026
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1209 N SUMMERBROOK AVE STE 100
MERIDIAN ID
83642-8750
US

IV. Provider business mailing address

1209 N SUMMERBROOK AVE STE 100
MERIDIAN ID
83642-8750
US

V. Phone/Fax

Practice location:
  • Phone: 208-938-5823
  • Fax:
Mailing address:
  • Phone: 208-938-5823
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number2781120
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: