Healthcare Provider Details

I. General information

NPI: 1497449052
Provider Name (Legal Business Name): AUDREY NAM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2023
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3626 MARKET PL W STE 101
UNIVERSITY PLACE WA
98466-4340
US

IV. Provider business mailing address

3626 MARKET PL W STE 101
UNIVERSITY PLACE WA
98466-4340
US

V. Phone/Fax

Practice location:
  • Phone: 253-250-4986
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number30.027248
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: