Healthcare Provider Details

I. General information

NPI: 1386206480
Provider Name (Legal Business Name): AUTUMN RAYMOND LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2019
Last Update Date: 01/11/2026
Certification Date: 07/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4750 PALM AVE
RIVERSIDE CA
92501-4012
US

IV. Provider business mailing address

2743 ORANGE ST
RIVERSIDE CA
92501-2538
US

V. Phone/Fax

Practice location:
  • Phone: 951-686-0021
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN691815
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: