Healthcare Provider Details

I. General information

NPI: 1083085575
Provider Name (Legal Business Name): AUDRA A NOONAN APRN CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/09/2015
Last Update Date: 07/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1085 N MAIN ST
PROVIDENCE RI
02904-5719
US

IV. Provider business mailing address

1085 N MAIN ST
PROVIDENCE RI
02904-5719
US

V. Phone/Fax

Practice location:
  • Phone: 401-415-4618
  • Fax: 401-415-4348
Mailing address:
  • Phone: 401-415-4618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number264353
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN00762
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAPRN00762
License Number StateRI
# 4
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAPRN00762
License Number StateRI
# 5
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN00762
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: