Provider Demographics
NPI:1154899805
Name:CAVINS-EZELL, AUDREY L (APRN)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:L
Last Name:CAVINS-EZELL
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:
Other - Last Name:CAVINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 257
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98507-0257
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16000 CHRISTENSEN RD STE 200
Practice Address - Street 2:
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98188-2925
Practice Address - Country:US
Practice Address - Phone:833-719-0886
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-10
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3012865363LP0808X
WAAP61025837363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health