Healthcare Provider Details

I. General information

NPI: 1386340198
Provider Name (Legal Business Name): CONNOR RANDALL OVERBY PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2023
Last Update Date: 08/28/2024
Certification Date: 08/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1909 COMMERCE AVE
CULLMAN AL
35055-6151
US

IV. Provider business mailing address

1241 BLOUNT AVE
GUNTERSVILLE AL
35976-1831
US

V. Phone/Fax

Practice location:
  • Phone: 256-384-2211
  • Fax:
Mailing address:
  • Phone: 256-751-2201
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1-153880
License Number StateAL

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: