Provider Demographics
NPI:1902604630
Name:LAMAR, AUDREY
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:LAMAR
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 W 144TH ST APT 1A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10030-1339
Mailing Address - Country:US
Mailing Address - Phone:646-675-8437
Mailing Address - Fax:
Practice Address - Street 1:10030 DITMARS BLVD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11369-1333
Practice Address - Country:US
Practice Address - Phone:718-898-6471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-06
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20240803175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist