Provider Demographics
NPI:1679382923
Name:JOHNSON, AUTUMN M (LPN)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:M
Last Name:JOHNSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1707 US ROUTE 60 W
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:WV
Mailing Address - Zip Code:25541-1112
Mailing Address - Country:US
Mailing Address - Phone:304-743-8160
Mailing Address - Fax:
Practice Address - Street 1:1707 US ROUTE 60 W
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:WV
Practice Address - Zip Code:25541-1112
Practice Address - Country:US
Practice Address - Phone:304-743-8160
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-02
Last Update Date:2025-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV39109164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse