Provider Demographics
NPI:1447341300
Name:FARNSWORTH, AUDREY JEAN (OD)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:JEAN
Last Name:FARNSWORTH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 OLD GALLOWS RD STE 520
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22182-3970
Mailing Address - Country:US
Mailing Address - Phone:703-847-8899
Mailing Address - Fax:571-223-6780
Practice Address - Street 1:2067 S DRAKE RD
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49006-5713
Practice Address - Country:US
Practice Address - Phone:269-366-3664
Practice Address - Fax:269-366-3665
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2021-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1523152W00000X
MI4901004685152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZWDBTZMedicare PIN
MIOC97655Medicare PIN
MI0733500017Medicare PIN