MEDICARE: AUTUMN LYNN WHITE FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	216257	AR

General Provider Information

NPI Number	:	1760050132
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AUTUMN LYNN WHITE FNP-C

Provider Business Mailing Address
First Line	:	2280 HIGHWAY 63
Second Line	:
City	:	RISON
State	:	AR
Zip	:	71665-8992
Country	:	US
Telephone Number	:	870-723-2338
Fax Number	:

Provider Business Practice Location Address
First Line	:	7245 SHERIDAN RD
Second Line	:
City	:	WHITE HALL
State	:	AR
Zip	:	71602-3214
Country	:	US
Telephone Number	:	870-850-8055
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/14/2021
Last Update Date	:	06/14/2021

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