Provider Demographics
NPI:1457097891
Name:CUSTER-AUTEN, ALYSSA N
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:N
Last Name:CUSTER-AUTEN
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 1:107 CUNNINGHAM LN
Mailing Address - Street 2:
Mailing Address - City:WELLSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:26070-3088
Mailing Address - Country:US
Mailing Address - Phone:304-559-7742
Mailing Address - Fax:
Practice Address - Street 1:107 CUNNINGHAM LN
Practice Address - Street 2:
Practice Address - City:WELLSBURG
Practice Address - State:WV
Practice Address - Zip Code:26070-3088
Practice Address - Country:US
Practice Address - Phone:304-559-7742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV125553494Medicaid
WV1821206228Medicaid
WV1356607394Medicaid