Healthcare Provider Details

I. General information

NPI: 1285579672
Provider Name (Legal Business Name): AUTUMN DELAIN JUSIC MSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

791 NW SAVANNAH CIR
LAKE CITY FL
32055-8826
US

IV. Provider business mailing address

791 NW SAVANNAH CIR
LAKE CITY FL
32055-8826
US

V. Phone/Fax

Practice location:
  • Phone: 386-466-2827
  • Fax:
Mailing address:
  • Phone: 386-466-2827
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11047545
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: