Provider Demographics
NPI:1114671336
Name:AUTUMN ENLOE NUTRITION
Entity Type:Organization
Organization Name:AUTUMN ENLOE NUTRITION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:AUTUMN
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:ENLOE
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RD, LD, CLT
Authorized Official - Phone:651-504-3118
Mailing Address - Street 1:14436 57TH ST N.
Mailing Address - Street 2:
Mailing Address - City:OAK PARK HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55082
Mailing Address - Country:US
Mailing Address - Phone:651-504-3118
Mailing Address - Fax:
Practice Address - Street 1:14436 57TH ST N
Practice Address - Street 2:
Practice Address - City:OAK PARK HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55082
Practice Address - Country:US
Practice Address - Phone:651-504-3118
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty