Healthcare Provider Details

I. General information

NPI: 1811538218
Provider Name (Legal Business Name): AUTUMN BROOKE SCHNEIDER NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2019
Last Update Date: 12/31/2022
Certification Date: 12/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 CLINIC DR STE A
PARIS KY
40361-2166
US

IV. Provider business mailing address

24 CLINIC DR STE A
PARIS KY
40361-2166
US

V. Phone/Fax

Practice location:
  • Phone: 859-987-0302
  • Fax:
Mailing address:
  • Phone: 859-987-0302
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3013923
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: