Provider Demographics
NPI:1083469340
Name:WICHTERMAN, AUTUMN MARIE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:MARIE
Last Name:WICHTERMAN
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:653 EBY RD
Mailing Address - Street 2:
Mailing Address - City:SHILOH
Mailing Address - State:OH
Mailing Address - Zip Code:44878-8870
Mailing Address - Country:US
Mailing Address - Phone:141-956-5677
Mailing Address - Fax:
Practice Address - Street 1:8402 BLACKJACK RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:OH
Practice Address - Zip Code:43050-9193
Practice Address - Country:US
Practice Address - Phone:419-565-6772
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-20
Last Update Date:2024-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH0036198363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health