Provider Demographics
NPI:1295274710
Name:SMITH, AUTUMN FLADMO (MSHN)
Entity type:Individual
Prefix:MRS
First Name:AUTUMN
Middle Name:FLADMO
Last Name:SMITH
Suffix:
Gender:F
Credentials:MSHN
Other - Prefix:MRS
Other - First Name:AUTUMN
Other - Middle Name:NICOLE
Other - Last Name:FLADMO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSHN
Mailing Address - Street 1:4933 JUNEBERRY CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-6434
Mailing Address - Country:US
Mailing Address - Phone:818-378-2106
Mailing Address - Fax:
Practice Address - Street 1:4933 JUNEBERRY CT
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-6434
Practice Address - Country:US
Practice Address - Phone:818-378-2106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-16
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist