Healthcare Provider Details

I. General information

NPI: 1285168732
Provider Name (Legal Business Name): AUTUMN WAKE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2017
Last Update Date: 04/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6581 IRONBOUND BAY AVE
LAS VEGAS NV
89139-6130
US

IV. Provider business mailing address

6581 IRONBOUND BAY AVE
LAS VEGAS NV
89139-6130
US

V. Phone/Fax

Practice location:
  • Phone: 904-613-8255
  • Fax:
Mailing address:
  • Phone: 904-613-8255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberRN56095
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: