Healthcare Provider Details

I. General information

NPI: 1538774963
Provider Name (Legal Business Name): AUTUMN NICHOLE CRIST
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2020
Last Update Date: 09/11/2020
Certification Date: 09/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 VALLEY CT # 5
MOUNT HOPE WV
25880-9294
US

IV. Provider business mailing address

784 LUCAS RD
VICTOR WV
25938-6706
US

V. Phone/Fax

Practice location:
  • Phone: 305-663-5011
  • Fax:
Mailing address:
  • Phone: 304-663-5011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number82678
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: