=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235719394
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MRS. AUTUMN SAGE BENSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/13/2021
-----------------------------------------------------
Last Update Date | 02/03/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7289 WILSON ST
-----------------------------------------------------
City | DURANT
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74701-0817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-483-1212
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7289 WILSON ST
-----------------------------------------------------
City | DURANT
-----------------------------------------------------
State | OK
-----------------------------------------------------
Zip | 74701-0817
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-483-1212
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171400000X
-----------------------------------------------------
Taxonomy Name | Health & Wellness Coach
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 133N00000X
-----------------------------------------------------
Taxonomy Name | Nutritionist
-----------------------------------------------------
License Number | DX7962
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------