Provider Demographics
NPI:1841872801
Name:JUSTICE, AUTUMN VICTORIA (DO)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:VICTORIA
Last Name:JUSTICE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:124 C MCKINLEY RD
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:KY
Mailing Address - Zip Code:42629
Mailing Address - Country:US
Mailing Address - Phone:270-566-2453
Mailing Address - Fax:
Practice Address - Street 1:305 LANGDON ST
Practice Address - Street 2:
Practice Address - City:SOMERSET
Practice Address - State:KY
Practice Address - Zip Code:42503-2750
Practice Address - Country:US
Practice Address - Phone:606-679-7441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-28
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY05621207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program