Healthcare Provider Details

I. General information

NPI: 1770538977
Provider Name (Legal Business Name): PAMELA J BLAKE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 07/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 19TH ST S
BIRMINGHAM AL
35249-1900
US

IV. Provider business mailing address

PO BOX 55310
BIRMINGHAM AL
35255-5310
US

V. Phone/Fax

Practice location:
  • Phone: 205-934-6600
  • Fax:
Mailing address:
  • Phone: 205-731-9701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number1054391
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: