Provider Demographics
NPI:1124762323
Name:FRIES, AUTUMN
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:FRIES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 PEGASUS CT STE 500
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:VA
Mailing Address - Zip Code:22602-4596
Mailing Address - Country:US
Mailing Address - Phone:304-702-7900
Mailing Address - Fax:
Practice Address - Street 1:500 PEGASUS COURT
Practice Address - Street 2:
Practice Address - City:WINCHESTER
Practice Address - State:VA
Practice Address - Zip Code:22602-4596
Practice Address - Country:US
Practice Address - Phone:800-805-6989
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-24
Last Update Date:2022-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV36115164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse