Healthcare Provider Details

I. General information

NPI: 1235719394
Provider Name (Legal Business Name): MRS. AUTUMN SAGE BENSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AUTUMN SAGE YODER

II. Dates (important events)

Enumeration Date: 04/13/2021
Last Update Date: 02/03/2026
Certification Date: 02/03/2026
Deactivation Date: 05/17/2025
Reactivation Date: 09/19/2025

III. Provider practice location address

7289 WILSON ST
DURANT OK
74701-0817
US

IV. Provider business mailing address

7289 WILSON ST
DURANT OK
74701-0817
US

V. Phone/Fax

Practice location:
  • Phone: 814-483-1212
  • Fax:
Mailing address:
  • Phone: 814-483-1212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberDX7962
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: