Provider Demographics
NPI:1871368662
Name:ORTA, AUTUMN ALYSE
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:ALYSE
Last Name:ORTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AUTUMN
Other - Middle Name:ALYSE
Other - Last Name:ANDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:640 N SCOTT ST
Mailing Address - Street 2:
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-1369
Mailing Address - Country:US
Mailing Address - Phone:734-657-5929
Mailing Address - Fax:
Practice Address - Street 1:775 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CHELSEA
Practice Address - State:MI
Practice Address - Zip Code:48118-1383
Practice Address - Country:US
Practice Address - Phone:734-593-6269
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker