Provider Demographics
NPI:1740829639
Name:MCGOVERN, AUTUMN MARIE I
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:MARIE
Last Name:MCGOVERN
Suffix:I
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 1:2775 E LANSING DR
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-7755
Mailing Address - Country:US
Mailing Address - Phone:616-226-2857
Mailing Address - Fax:
Practice Address - Street 1:1484 N M 52
Practice Address - Street 2:
Practice Address - City:OWOSSO
Practice Address - State:MI
Practice Address - Zip Code:48867-1235
Practice Address - Country:US
Practice Address - Phone:770-373-5822
Practice Address - Fax:248-712-4381
Is Sole Proprietor?:No
Enumeration Date:2019-12-26
Last Update Date:2021-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant