Healthcare Provider Details

I. General information

NPI: 1174020929
Provider Name (Legal Business Name): KAYLA KIZZIAH TIDWELL CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KAYLA DANIELLE KIZZIAH CRNP

II. Dates (important events)

Enumeration Date: 04/09/2018
Last Update Date: 12/26/2020
Certification Date: 12/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3316 HIGHWAY 280
ALEXANDER CITY AL
35010-3369
US

IV. Provider business mailing address

1034 S TALLASSEE ST
DADEVILLE AL
36853-1844
US

V. Phone/Fax

Practice location:
  • Phone: 256-329-7100
  • Fax:
Mailing address:
  • Phone: 256-825-9900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-145314
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: