Healthcare Provider Details

I. General information

NPI: 1124705637
Provider Name (Legal Business Name): BETHANY CHANCELOR CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2023
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1107 14TH AVE SE STE 300
DECATUR AL
35601-3368
US

IV. Provider business mailing address

1107 14TH AVE SE STE 300
DECATUR AL
35601-3368
US

V. Phone/Fax

Practice location:
  • Phone: 256-350-0362
  • Fax: 256-355-9779
Mailing address:
  • Phone: 256-350-0362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-134008
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: