Healthcare Provider Details

I. General information

NPI: 1841383585
Provider Name (Legal Business Name): KANDACE SHOULTS CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

208 PIERSON AVE
CENTREVILLE AL
35042-2918
US

IV. Provider business mailing address

208 PIERSON AVE
CENTREVILLE AL
35042-2918
US

V. Phone/Fax

Practice location:
  • Phone: 205-926-4881
  • Fax:
Mailing address:
  • Phone: 205-926-4881
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number1-074326
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: