=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104248616
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AUDRA CHRISTAL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/17/2014
-----------------------------------------------------
Last Update Date | 01/17/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8020 126TH ST W
-----------------------------------------------------
City | ANDALUSIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61232-9235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-682-8372
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8020 126TH ST W
-----------------------------------------------------
City | ANDALUSIA
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61232-9235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-682-8372
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 12312015
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------