Provider Demographics
NPI:1164818845
Name:FISHER, AUDREY L (ANP)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:L
Last Name:FISHER
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:487 LAKE AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:SAINT JAMES
Mailing Address - State:NY
Mailing Address - Zip Code:11780-2277
Mailing Address - Country:US
Mailing Address - Phone:631-584-6152
Mailing Address - Fax:
Practice Address - Street 1:487 LAKE AVE STE 2
Practice Address - Street 2:
Practice Address - City:SAINT JAMES
Practice Address - State:NY
Practice Address - Zip Code:11780-2277
Practice Address - Country:US
Practice Address - Phone:631-584-6152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-09
Last Update Date:2015-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF307001-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health