Provider Demographics
NPI:1457243321
Name:KOPPENHAVER, AUTUMN ROSE (CRNP)
Entity type:Individual
Prefix:
First Name:AUTUMN
Middle Name:ROSE
Last Name:KOPPENHAVER
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 325
Mailing Address - Street 2:
Mailing Address - City:HEGINS
Mailing Address - State:PA
Mailing Address - Zip Code:17938-0325
Mailing Address - Country:US
Mailing Address - Phone:570-573-4836
Mailing Address - Fax:
Practice Address - Street 1:4897 US-209
Practice Address - Street 2:
Practice Address - City:ELIZABETHVILLE
Practice Address - State:PA
Practice Address - Zip Code:17023
Practice Address - Country:US
Practice Address - Phone:717-362-3371
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-16
Last Update Date:2025-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP033234207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine