Basic Information
| Provider Information | |||||||||
| NPI: | 1538810171 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HERRING | ||||||||
| FirstName: | AUDRA | ||||||||
| MiddleName: | CORNELIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1505 W GRANDE BLVD APT 513 | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757035687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9032798956 | ||||||||
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| Practice Location | |||||||||
| Address1: | 910 E HOUSTON ST STE 600 | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757028304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035262644 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/14/2022 | ||||||||
| LastUpdateDate: | 01/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZC0007X | Y | 193400000X SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant |
No ID Information.