Provider Demographics
NPI:1851174437
Name:KING, CHEYENE AUTUMN
Entity Type:Individual
Prefix:
First Name:CHEYENE
Middle Name:AUTUMN
Last Name:KING
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 1:2550 NATURE PARK DR
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89084-3204
Mailing Address - Country:US
Mailing Address - Phone:702-859-4710
Mailing Address - Fax:
Practice Address - Street 1:2550 NATURE PARK DR
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89084-3204
Practice Address - Country:US
Practice Address - Phone:702-859-4710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-16
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ014078225200000X
NVA-1536225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant