Healthcare Provider Details

I. General information

NPI: 1972953081
Provider Name (Legal Business Name): SENECA WALDEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2016
Last Update Date: 06/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1505 DAPHNE AVE
DAPHNE AL
36526-4298
US

IV. Provider business mailing address

1505 DAPHNE AVE
DAPHNE AL
36526-4298
US

V. Phone/Fax

Practice location:
  • Phone: 251-625-2663
  • Fax: 251-625-3198
Mailing address:
  • Phone: 251-625-2663
  • Fax: 251-625-3198

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-130973
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: