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NPI Code Detail

MEDICARE: AUTUMN BLACK

MEDICARE: AUTUMN BLACK
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363LF0000XFamily Nurse Practitioner3014903KY

General Provider Information

NPI Number : 1376137414
Entity Type Code : Individual
Provider Name (Legal Business Name) : AUTUMN BLACK
Provider Business Mailing Address
First Line : 909 RIDGEBROOK RD STE 300
Second Line :
City : SPARKS
State : MD
Zip : 21152-9477
Country : US
Telephone Number : 443-383-9300
Fax Number :
Provider Business Practice Location Address
First Line : 2100 MILLVALE RD
Second Line :
City : LOUISVILLE
State : KY
Zip : 40205-1604
Country : US
Telephone Number : 443-383-9300
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 03/01/2021
Last Update Date : 11/17/2022

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Directions to “ AUTUMN BLACK ” Practice Location

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