Healthcare Provider Details

I. General information

NPI: 1356205009
Provider Name (Legal Business Name): AUTUMN ANGEL MCDERMOTT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/16/2025
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6200 N LA CHOLLA BLVD
TUCSON AZ
85741-3529
US

IV. Provider business mailing address

37948 58TH ST E
PALMDALE CA
93552-3911
US

V. Phone/Fax

Practice location:
  • Phone: 661-618-5465
  • Fax:
Mailing address:
  • Phone: 661-618-5465
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number304847
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: