Provider Demographics
NPI:1053193706
Name:LOVELACE, AUDREY LYNN (LMBT 09629)
Entity type:Individual
Prefix:MS
First Name:AUDREY
Middle Name:LYNN
Last Name:LOVELACE
Suffix:
Gender:F
Credentials:LMBT 09629
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 TWILA LN
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27288-4339
Mailing Address - Country:US
Mailing Address - Phone:336-589-0347
Mailing Address - Fax:
Practice Address - Street 1:109 TWILA LN
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-4339
Practice Address - Country:US
Practice Address - Phone:336-589-0347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-17
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC09629225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist