Basic Information
Provider Information | |||||||||
NPI: | 1619520202 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ANDERS | ||||||||
FirstName: | AUTUMN | ||||||||
MiddleName: | NICOLE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | WHNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | WILLIAMS | ||||||||
OtherFirstName: | AUTUMN | ||||||||
OtherMiddleName: | NICOLE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 300 E MCBEE AVE FL 4 | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | SC | ||||||||
PostalCode: | 296012842 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8645228603 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1120 GROVE RD | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | SC | ||||||||
PostalCode: | 296054656 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8644558897 | ||||||||
FaxNumber: | 8644558555 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/23/2019 | ||||||||
LastUpdateDate: | 10/22/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/22/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WM0102X | 109747 | SC | N | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Providers | Registered Nurse | Maternal Newborn | 363LW0102X | 24030 | SC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health |
No ID Information.