Healthcare Provider Details

I. General information

NPI: 1730090598
Provider Name (Legal Business Name): AUTUMN A ROUKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2026
Last Update Date: 09/12/2026
Certification Date: 09/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

167 OAK TERRACE DR
CRESTVIEW FL
32539-8382
US

IV. Provider business mailing address

167 OAK TERRACE DR
CRESTVIEW FL
32539-8382
US

V. Phone/Fax

Practice location:
  • Phone: 850-496-5573
  • Fax:
Mailing address:
  • Phone: 850-496-5573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number9558212
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: