1386204329 NPI number — AUTUMN SAMANTHA LONGWORTH CRNA

Table of content: AUTUMN SAMANTHA LONGWORTH CRNA (NPI 1386204329)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386204329 NPI number — AUTUMN SAMANTHA LONGWORTH CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LONGWORTH
Provider First Name:
AUTUMN
Provider Middle Name:
SAMANTHA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MESSER
Provider Other First Name:
AUTUMN
Provider Other Middle Name:
SAMANTHA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
CRNA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1386204329
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
DEPT 888618
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KNOXVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37995-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-915-9942
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
273 WINE CIR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BLOUNTVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37617-4315
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-416-1678
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/20/2019

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: 367500000X , with the licence number:  0024177740 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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