Healthcare Provider Details

I. General information

NPI: 1629752043
Provider Name (Legal Business Name): ANNABELLE BOTHEM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JUDE BOTHEM

II. Dates (important events)

Enumeration Date: 06/14/2023
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 US HIGHWAY 31 S
DECATUR AL
35603-1644
US

IV. Provider business mailing address

2194 KEEL MOUNTAIN RD
GURLEY AL
35748-9161
US

V. Phone/Fax

Practice location:
  • Phone: 256-260-1660
  • Fax:
Mailing address:
  • Phone: 801-385-1691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: