Provider Demographics
NPI:1699310508
Name:POWELL, AUTUMN (FNP-C)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:POWELL
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 179
Mailing Address - Street 2:
Mailing Address - City:STIGLER
Mailing Address - State:OK
Mailing Address - Zip Code:74462-0179
Mailing Address - Country:US
Mailing Address - Phone:918-967-3368
Mailing Address - Fax:918-967-4582
Practice Address - Street 1:204 WALL ST STE A
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953-4400
Practice Address - Country:US
Practice Address - Phone:918-647-2155
Practice Address - Fax:918-647-4095
Is Sole Proprietor?:No
Enumeration Date:2019-11-14
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK114096363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKF07191362OtherAMERICAN ASSOCIATION OF NURSE PRACTITIONERS