Healthcare Provider Details

I. General information

NPI: 1164098893
Provider Name (Legal Business Name): AUTUMN RAE NUNN KILLOP OD, MPH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2021
Last Update Date: 03/03/2025
Certification Date: 03/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2820 E BELTLINE LN NE
GRAND RAPIDS MI
49525-9432
US

IV. Provider business mailing address

2820 E BELTLINE LN NE
GRAND RAPIDS MI
49525-9432
US

V. Phone/Fax

Practice location:
  • Phone: 616-363-5413
  • Fax: 616-363-4211
Mailing address:
  • Phone: 766-363-5413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4901005523
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: