MEDICARE: AUTUMN GODE CNS

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
1	364SA2200X	Adult Health Clinical Nurse Specialist	R1532768	MN

General Provider Information

NPI Number	:	1881932267
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUTUMN GODE CNS

Provider Business Mailing Address
First Line	:	6520 FRANKLIN HILLS RD
Second Line	:
City	:	INDEPENDENCE
State	:	MN
Zip	:	55359-9424
Country	:	US
Telephone Number	:	612-723-1979
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 E 28TH ST
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55407-3723
Country	:	US
Telephone Number	:	612-863-3688
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/20/2013
Last Update Date	:	01/20/2013

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