Healthcare Provider Details

I. General information

NPI: 1710273875
Provider Name (Legal Business Name): AUTUMN LEA CONKLIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2011
Last Update Date: 06/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

289 NORTH AVE
WASHINGTON PA
15301-3512
US

IV. Provider business mailing address

4297 PROSPERITY PIKE
PROSPERITY PA
15329-1254
US

V. Phone/Fax

Practice location:
  • Phone: 724-223-7801
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberRN626758
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: