Provider Demographics
NPI:1184206872
Name:GRANT, AUTUMN (FNP)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:
Last Name:GRANT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 W USTICK RD STE 100
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83646-7734
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1430 W USTICK RD STE 100
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83646-7734
Practice Address - Country:US
Practice Address - Phone:208-286-8670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-22
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ260694363LF0000X
ID77541363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
F03211332OtherAMERICAN ACADEMY OF NURSE PRACTITIONERS
AZ260694OtherARIZONA STATE BOARD OF NURSING
ID77541OtherIDAHO BOARD OF NURSING