Provider Demographics
NPI:1306683255
Name:MICROBLADING BY AUTUMN LLC
Entity type:Organization
Organization Name:MICROBLADING BY AUTUMN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHOTOREALISTIC AREOLA SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:AUTUMN
Authorized Official - Middle Name:WIND
Authorized Official - Last Name:SHARP
Authorized Official - Suffix:
Authorized Official - Credentials:TATTOO ARTIST
Authorized Official - Phone:417-763-5414
Mailing Address - Street 1:1554 N PEARSON DR
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-9436
Mailing Address - Country:US
Mailing Address - Phone:417-763-5414
Mailing Address - Fax:
Practice Address - Street 1:4058 S LONE PINE AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-6605
Practice Address - Country:US
Practice Address - Phone:417-763-5414
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-09
Last Update Date:2024-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherGroup - Multi-Specialty