Healthcare Provider Details

I. General information

NPI: 1841105228
Provider Name (Legal Business Name): AUTUMN D ROSE
Entity Type: Individual
Gender:
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2026
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 220
BRIDGEPORT WV
26330-0220
US

IV. Provider business mailing address

PO BOX 220
BRIDGEPORT WV
26330-0220
US

V. Phone/Fax

Practice location:
  • Phone: 304-933-3073
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: