Healthcare Provider Details

I. General information

NPI: 1982087631
Provider Name (Legal Business Name): AUTUMN JADE SPELLMEIER APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AUTUMN JADE MOSIER RN

II. Dates (important events)

Enumeration Date: 06/30/2015
Last Update Date: 05/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 WILLOW RD
GOODLAND KS
67735-1518
US

IV. Provider business mailing address

106 WILLOW RD
GOODLAND KS
67735-1518
US

V. Phone/Fax

Practice location:
  • Phone: 785-890-6075
  • Fax: 785-890-6077
Mailing address:
  • Phone: 785-890-4012
  • Fax: 785-890-6077

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number53-76843-091
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: