Healthcare Provider Details

I. General information

NPI: 1245959667
Provider Name (Legal Business Name): AUTUMN CULLISON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2022
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 E LAKE SHORE DR
DECATUR IL
62521-3810
US

IV. Provider business mailing address

23453 COVERED BRIDGE RD
ATHENS IL
62613-7606
US

V. Phone/Fax

Practice location:
  • Phone: 217-464-2966
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209028286
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: