Provider Demographics
NPI:1245959667
Name:CULLISON, AUTUMN (RN)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:CULLISON
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 1:23453 COVERED BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:IL
Mailing Address - Zip Code:62613-7606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 E LAKE SHORE DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-3810
Practice Address - Country:US
Practice Address - Phone:217-464-2966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-29
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209028286367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered