Healthcare Provider Details

I. General information

NPI: 1275082430
Provider Name (Legal Business Name): TIFFANY BETTS WALLER CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2016
Last Update Date: 09/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 LAKESHORE DR SUITE 150
BIRMINGHAM AL
35209-8803
US

IV. Provider business mailing address

2200 LAKESHORE DR SUITE 150
BIRMINGHAM AL
35209-8803
US

V. Phone/Fax

Practice location:
  • Phone: 205-871-6926
  • Fax: 205-871-7981
Mailing address:
  • Phone: 205-871-6926
  • Fax: 205-871-7981

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1-137729
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: