Healthcare Provider Details

I. General information

NPI: 1598995417
Provider Name (Legal Business Name): AUTUMN MARIE MARTIN MS,FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AUTUMN MARIE KELLER MS,FNP

II. Dates (important events)

Enumeration Date: 07/27/2009
Last Update Date: 05/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 CEDAR ST
JULESBURG CO
80737-1121
US

IV. Provider business mailing address

900 CEDAR ST
JULESBURG CO
80737-1121
US

V. Phone/Fax

Practice location:
  • Phone: 970-353-9403
  • Fax: 970-353-9906
Mailing address:
  • Phone: 970-353-9403
  • Fax: 970-353-9906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP10050
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: