Healthcare Provider Details

I. General information

NPI: 1285386086
Provider Name (Legal Business Name): AUTUMN MARTIN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/23/2022
Last Update Date: 03/17/2022
Certification Date: 03/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 WELLNESS DR
MIDLAND MI
48670-2400
US

IV. Provider business mailing address

4000 WELLNESS DR
MIDLAND MI
48670-8915
US

V. Phone/Fax

Practice location:
  • Phone: 844-832-1956
  • Fax:
Mailing address:
  • Phone: 844-832-1956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704302862
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: