Healthcare Provider Details

I. General information

NPI: 1790370187
Provider Name (Legal Business Name): MAKENZIE KRAMER SHADRICK CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/08/2021
Last Update Date: 03/08/2021
Certification Date: 03/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 LEIGHTON AVE
ANNISTON AL
36207-5701
US

IV. Provider business mailing address

1001 LEIGHTON AVE
ANNISTON AL
36207-5701
US

V. Phone/Fax

Practice location:
  • Phone: 256-237-1618
  • Fax: 256-237-2661
Mailing address:
  • Phone: 256-237-1618
  • Fax: 256-237-2661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number155278
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: