MEDICARE: AUDRA HAIRSTON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	175T00000X	Peer Specialist	13091	ID

General Provider Information

NPI Number	:	1750244331
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUDRA HAIRSTON

Provider Business Mailing Address
First Line	:	598 ADDISON AVE W
Second Line	:
City	:	TWIN FALLS
State	:	ID
Zip	:	83301-5039
Country	:	US
Telephone Number	:	208-682-1951
Fax Number	:

Provider Business Practice Location Address
First Line	:	598 ADDISON AVE W
Second Line	:
City	:	TWIN FALLS
State	:	ID
Zip	:	83301-5039
Country	:	US
Telephone Number	:	208-682-1951
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/09/2025
Last Update Date	:	12/10/2025

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Directions to “ AUDRA HAIRSTON ” Practice Location

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