Provider Demographics
NPI:1912221789
Name:BLAIS, AUTUMN SOLEIL (PNP)
Entity type:Individual
Prefix:MS
First Name:AUTUMN
Middle Name:SOLEIL
Last Name:BLAIS
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 WARDON RD
Mailing Address - Street 2:
Mailing Address - City:PUTNEY
Mailing Address - State:VT
Mailing Address - Zip Code:05346-6738
Mailing Address - Country:US
Mailing Address - Phone:802-579-8454
Mailing Address - Fax:
Practice Address - Street 1:209 AUSTINE DR
Practice Address - Street 2:
Practice Address - City:BRATTLEBORO
Practice Address - State:VT
Practice Address - Zip Code:05301-7223
Practice Address - Country:US
Practice Address - Phone:802-579-8454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-22
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101.0135494363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics