1003917162 NPI number — MRS. AUTUMN BROOKE BOYD LPN

Table of content: MRS. AUTUMN BROOKE BOYD LPN (NPI 1003917162)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003917162 NPI number — MRS. AUTUMN BROOKE BOYD LPN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOYD
Provider First Name:
AUTUMN
Provider Middle Name:
BROOKE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LPN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003917162
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 155
Provider Second Line Business Mailing Address:
REA CLINIC
Provider Business Mailing Address City Name:
CHRISTOPHER
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62822
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-724-2401
Provider Business Mailing Address Fax Number:
618-724-2571

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
119 GAS PLANT ROAD
Provider Second Line Business Practice Location Address:
REA CLINIC DU QUOIN
Provider Business Practice Location Address City Name:
DU QUOIN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62832
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-542-8702
Provider Business Practice Location Address Fax Number:
618-542-8792
Provider Enumeration Date:
09/25/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 164W00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)