Healthcare Provider Details

I. General information

NPI: 1790275949
Provider Name (Legal Business Name): AUDREY WAND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2018
Last Update Date: 05/23/2021
Certification Date: 05/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 S LAKELINE BLVD STE 100
CEDAR PARK TX
78613-2968
US

IV. Provider business mailing address

6000 SHEPHERD MOUNTAIN CV UNIT 906
AUSTIN TX
78730-4904
US

V. Phone/Fax

Practice location:
  • Phone: 512-345-8970
  • Fax:
Mailing address:
  • Phone: 512-942-9642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number857866
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAP138098
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: