Provider Demographics
NPI:1265830434
Name:ALTHEIDE, AUTUMN (CRNA)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:ALTHEIDE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:AUTUMN
Other - Middle Name:
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:800 E CARPENTER ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-5324
Mailing Address - Country:US
Mailing Address - Phone:217-525-5643
Mailing Address - Fax:217-544-2521
Practice Address - Street 1:800 E CARPENTER ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-5324
Practice Address - Country:US
Practice Address - Phone:217-525-5643
Practice Address - Fax:217-544-2521
Is Sole Proprietor?:No
Enumeration Date:2014-12-19
Last Update Date:2021-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209012547367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered