Provider Demographics
NPI:1629472071
Name:SMITH, AUTUM PENN (RN)
Entity Type:Individual
Prefix:MRS
First Name:AUTUM
Middle Name:PENN
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1518 DILLOWAY DR
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-2786
Mailing Address - Country:US
Mailing Address - Phone:989-948-3369
Mailing Address - Fax:
Practice Address - Street 1:1518 DILLOWAY DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48640-2786
Practice Address - Country:US
Practice Address - Phone:989-948-3369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-14
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704226537163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health