Provider Demographics
NPI:1447504543
Name:AUDET, THERESA MARIE (RN)
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:MARIE
Last Name:AUDET
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3165 HARBOR LN N
Mailing Address - Street 2:#2-104
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-5130
Mailing Address - Country:US
Mailing Address - Phone:612-910-4832
Mailing Address - Fax:
Practice Address - Street 1:3165 HARBOR LN N
Practice Address - Street 2:#2-104
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55447-5130
Practice Address - Country:US
Practice Address - Phone:612-910-4832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-29
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 177731-6163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse