Healthcare Provider Details

I. General information

NPI: 1457853764
Provider Name (Legal Business Name): AUTUMN LYNN MCCLINTON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/02/2018
Last Update Date: 03/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3201 CHERRY RIDGE ST STE D400
SAN ANTONIO TX
78230-4820
US

IV. Provider business mailing address

7106 RIDGE PORT DR # 323919
CONVERSE TX
78109-2747
US

V. Phone/Fax

Practice location:
  • Phone: 210-692-0222
  • Fax:
Mailing address:
  • Phone: 210-943-2264
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number323919
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: