Provider Demographics
NPI:1265985089
Name:SHORTER, AUTUMN
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:SHORTER
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 1:1427 MAGNOLIA DR
Mailing Address - Street 2:
Mailing Address - City:INKSTER
Mailing Address - State:MI
Mailing Address - Zip Code:48141-1784
Mailing Address - Country:US
Mailing Address - Phone:313-740-8425
Mailing Address - Fax:
Practice Address - Street 1:1427 MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:INKSTER
Practice Address - State:MI
Practice Address - Zip Code:48141-1784
Practice Address - Country:US
Practice Address - Phone:313-740-8425
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-28
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703116990164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse