Provider Demographics
NPI:1134727811
Name:SONG, AUTUMN SEUNGHEE (DNP)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:SEUNGHEE
Last Name:SONG
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:SEUNGHEE
Other - Middle Name:
Other - Last Name:SONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DNP
Mailing Address - Street 1:820 S WOOD ST # MC808
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4325
Mailing Address - Country:US
Mailing Address - Phone:312-996-7006
Mailing Address - Fax:312-996-4238
Practice Address - Street 1:1801 W TAYLOR ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4795
Practice Address - Country:US
Practice Address - Phone:312-413-7500
Practice Address - Fax:312-413-3856
Is Sole Proprietor?:No
Enumeration Date:2020-10-14
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209021694363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health