Provider Demographics
NPI:1538774963
Name:CRIST, AUTUMN NICHOLE
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:NICHOLE
Last Name:CRIST
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 1:784 LUCAS RD
Mailing Address - Street 2:
Mailing Address - City:VICTOR
Mailing Address - State:WV
Mailing Address - Zip Code:25938-6706
Mailing Address - Country:US
Mailing Address - Phone:304-663-5011
Mailing Address - Fax:
Practice Address - Street 1:170 VALLEY CT # 5
Practice Address - Street 2:
Practice Address - City:MOUNT HOPE
Practice Address - State:WV
Practice Address - Zip Code:25880-9294
Practice Address - Country:US
Practice Address - Phone:305-663-5011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-11
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV82678376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide