Healthcare Provider Details

I. General information

NPI: 1912482936
Provider Name (Legal Business Name): AUTUMN NICHOLE KIRK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2018
Last Update Date: 10/07/2020
Certification Date: 10/07/2020
Deactivation Date: 10/19/2018
Reactivation Date: 01/16/2019

III. Provider practice location address

104 E CULVER RD STE 102
KNOX IN
46534-2241
US

IV. Provider business mailing address

2022 KELLE DR
CHESTERTON IN
46304-8708
US

V. Phone/Fax

Practice location:
  • Phone: 574-772-7918
  • Fax: 574-772-0894
Mailing address:
  • Phone: 219-364-4004
  • Fax: 219-326-2584

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28172692A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71008625A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: