Provider Demographics
NPI:1902297203
Name:CAVENDER-WILSON, AUTUMN ALISE (CPM, LTM)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:ALISE
Last Name:CAVENDER-WILSON
Suffix:
Gender:F
Credentials:CPM, LTM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2643 540TH ST
Mailing Address - Street 2:
Mailing Address - City:GRANITE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56241-3625
Mailing Address - Country:US
Mailing Address - Phone:320-444-5645
Mailing Address - Fax:
Practice Address - Street 1:2643 540TH ST
Practice Address - Street 2:
Practice Address - City:GRANITE FALLS
Practice Address - State:MN
Practice Address - Zip Code:56241-3625
Practice Address - Country:US
Practice Address - Phone:320-444-5645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-09
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1042176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife