Provider Demographics
NPI:1619791647
Name:ORDILLE, AUTUMN RAE
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:RAE
Last Name:ORDILLE
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:ONE MEDICAL CENTER BLVD
Mailing Address - Street 2:BLDG 1 STE 400
Mailing Address - City:UPLAND
Mailing Address - State:PA
Mailing Address - Zip Code:19013
Mailing Address - Country:US
Mailing Address - Phone:610-876-2400
Mailing Address - Fax:610-876-4308
Practice Address - Street 1:ONE MEDICAL CENTER BLVD
Practice Address - Street 2:BLDG 1 STE 400
Practice Address - City:UPLAND
Practice Address - State:PA
Practice Address - Zip Code:19013
Practice Address - Country:US
Practice Address - Phone:610-876-2400
Practice Address - Fax:610-876-4308
Is Sole Proprietor?:No
Enumeration Date:2024-11-15
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP030724363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily