Healthcare Provider Details

I. General information

NPI: 1932358157
Provider Name (Legal Business Name): MICHEAL ANTHONY SPANN R.D.,C.D.E.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2008
Last Update Date: 09/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 WOODLEIGH RD
DOTHAN AL
36305-1036
US

IV. Provider business mailing address

305 WOODLEIGH RD
DOTHAN AL
36305-1036
US

V. Phone/Fax

Practice location:
  • Phone: 334-793-7260
  • Fax:
Mailing address:
  • Phone: 334-793-7260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number225
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number225
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number225
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: