Provider Demographics
NPI:1609625334
Name:VALENTINE, AUTUMN M (RN)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:M
Last Name:VALENTINE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 FORDHAM PL
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-8003
Mailing Address - Country:US
Mailing Address - Phone:631-968-1247
Mailing Address - Fax:
Practice Address - Street 1:885 HAMPSHIRE RD
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-7631
Practice Address - Country:US
Practice Address - Phone:631-968-1247
Practice Address - Fax:631-968-1807
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY822809163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse