Provider Demographics
NPI:1891593760
Name:MAZZELLA, AUTUMN
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:MAZZELLA
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3836 SLEEPY HOLLOW DR
Mailing Address - Street 2:
Mailing Address - City:HURRICANE
Mailing Address - State:WV
Mailing Address - Zip Code:25526-9148
Mailing Address - Country:US
Mailing Address - Phone:304-619-9489
Mailing Address - Fax:
Practice Address - Street 1:900 VIRGINIA ST E STE 400
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-2835
Practice Address - Country:US
Practice Address - Phone:681-313-4759
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-05
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV39889164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse