Healthcare Provider Details

I. General information

NPI: 1710626924
Provider Name (Legal Business Name): AUTUMN ANN GWINN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2022
Last Update Date: 06/03/2022
Certification Date: 06/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

534 WALLACE RD APT 203
AMES IA
50011-4008
US

IV. Provider business mailing address

3914 MARICOPA DR APT 203
AMES IA
50014-8097
US

V. Phone/Fax

Practice location:
  • Phone: 515-294-8009
  • Fax:
Mailing address:
  • Phone: 641-203-7202
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: