Provider Demographics
NPI:1588419717
Name:THOMAS, AUTUMN E (MS, RD, LD)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:E
Last Name:THOMAS
Suffix:
Gender:
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:AUTUMN
Other - Middle Name:E
Other - Last Name:HOLLOWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2503 N YORKCHASE LN
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-3106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20325 N 51ST AVE STE 126
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-5677
Practice Address - Country:US
Practice Address - Phone:602-341-5248
Practice Address - Fax:602-702-5219
Is Sole Proprietor?:No
Enumeration Date:2024-04-22
Last Update Date:2025-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX86175394133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered