Provider Demographics
NPI:1063799245
Name:NETTLES, AUTUMN DAWN (RN)
Entity type:Individual
Prefix:MS
First Name:AUTUMN
Middle Name:DAWN
Last Name:NETTLES
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 N MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:WELLSTON
Mailing Address - State:OH
Mailing Address - Zip Code:45692-1144
Mailing Address - Country:US
Mailing Address - Phone:740-418-8420
Mailing Address - Fax:
Practice Address - Street 1:104 N MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:WELLSTON
Practice Address - State:OH
Practice Address - Zip Code:45692-1144
Practice Address - Country:US
Practice Address - Phone:740-418-8420
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-15
Last Update Date:2017-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.118312-MEDS164W00000X
OHRN.379485163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse