Provider Demographics
NPI:1902779036
Name:WISNER, AUTUMN
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:WISNER
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 1:138 HIDDEN LN
Mailing Address - Street 2:
Mailing Address - City:ALDERSON
Mailing Address - State:WV
Mailing Address - Zip Code:24910-1159
Mailing Address - Country:US
Mailing Address - Phone:304-646-9791
Mailing Address - Fax:
Practice Address - Street 1:138 HIDDEN LN
Practice Address - Street 2:
Practice Address - City:ALDERSON
Practice Address - State:WV
Practice Address - Zip Code:24910-1159
Practice Address - Country:US
Practice Address - Phone:304-646-9791
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-25
Last Update Date:2025-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide