Healthcare Provider Details

I. General information

NPI: 1215688627
Provider Name (Legal Business Name): KACY JO GRIFFITH TYNER CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2022
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

873 DENNISON AVE SW STE 102
BIRMINGHAM AL
35211-3867
US

IV. Provider business mailing address

405 BELCHER ST
CENTREVILLE AL
35042-2946
US

V. Phone/Fax

Practice location:
  • Phone: 205-774-3309
  • Fax: 205-316-7675
Mailing address:
  • Phone: 205-926-2992
  • Fax: 205-316-7675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1-176450
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1-176450
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: