Provider Demographics
NPI:1699232835
Name:VELASQUEZ, AUTUMN MARIE
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:MARIE
Last Name:VELASQUEZ
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 1:4768 ROONEY AVE
Mailing Address - Street 2:
Mailing Address - City:NEW FRANKLIN
Mailing Address - State:OH
Mailing Address - Zip Code:44319-4358
Mailing Address - Country:US
Mailing Address - Phone:724-691-4001
Mailing Address - Fax:
Practice Address - Street 1:4768 ROONEY AVE
Practice Address - Street 2:
Practice Address - City:NEW FRANKLIN
Practice Address - State:OH
Practice Address - Zip Code:44319-4358
Practice Address - Country:US
Practice Address - Phone:724-691-4001
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-25
Last Update Date:2019-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer