Healthcare Provider Details

I. General information

NPI: 1881932267
Provider Name (Legal Business Name): AUTUMN GODE CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/20/2013
Last Update Date: 01/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 E 28TH ST
MINNEAPOLIS MN
55407-3723
US

IV. Provider business mailing address

6520 FRANKLIN HILLS RD
INDEPENDENCE MN
55359-9424
US

V. Phone/Fax

Practice location:
  • Phone: 612-863-3688
  • Fax:
Mailing address:
  • Phone: 612-723-1979
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License NumberR1532768
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: