Provider Demographics
NPI:1104293471
Name:TA, AUTUMN (EAMP)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:TA
Suffix:
Gender:F
Credentials:EAMP
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:
Other - Last Name:TA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:637 141ST CT SE
Mailing Address - Street 2:APT F106
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98007-6757
Mailing Address - Country:US
Mailing Address - Phone:206-335-4907
Mailing Address - Fax:
Practice Address - Street 1:6869 WOODLAWN AVE NE
Practice Address - Street 2:SUITE 208
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-5469
Practice Address - Country:US
Practice Address - Phone:206-535-8867
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-21
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC60454090171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist