Healthcare Provider Details

I. General information

NPI: 1568614170
Provider Name (Legal Business Name): MELISSA SUZANNE BAGWELL-SEIFERT CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2008
Last Update Date: 07/23/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1965 AL HIGHWAY 157 SUITE B
CULLMAN AL
35058-0672
US

IV. Provider business mailing address

1965 AL HIGHWAY 157 SUITE B
CULLMAN AL
35058-0672
US

V. Phone/Fax

Practice location:
  • Phone: 256-775-2722
  • Fax: 256-775-2648
Mailing address:
  • Phone: 256-775-2722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number1-087518
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier182072
Identifier TypeMEDICAID
Identifier StateAL
Identifier Issuer
# 2
Identifier1-087518
Identifier TypeOTHER
Identifier StateAL
Identifier IssuerALABAMA BOARD OF NURSING LICENSE NUMBER

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: