Provider Demographics
NPI:1083320105
Name:SHRADER, AUTUMN NICOLE
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:NICOLE
Last Name:SHRADER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5187 KELLYS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25312-6843
Mailing Address - Country:US
Mailing Address - Phone:304-590-6313
Mailing Address - Fax:
Practice Address - Street 1:5187 KELLYS CREEK RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25312-6843
Practice Address - Country:US
Practice Address - Phone:304-590-6313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant