Provider Demographics
NPI:1174946859
Name:ZONGRONE, AUDREY
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:ZONGRONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 E KILLARNEY LK
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:SC
Mailing Address - Zip Code:29369-9489
Mailing Address - Country:US
Mailing Address - Phone:864-517-2804
Mailing Address - Fax:
Practice Address - Street 1:350 E KILLARNEY LK
Practice Address - Street 2:
Practice Address - City:MOORE
Practice Address - State:SC
Practice Address - Zip Code:29369-9489
Practice Address - Country:US
Practice Address - Phone:864-517-2804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-30
Last Update Date:2014-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3395225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist