Healthcare Provider Details

I. General information

NPI: 1063113033
Provider Name (Legal Business Name): KELLY S. SHERRILL CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2023
Last Update Date: 03/15/2023
Certification Date: 03/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1118 ROSS CLARK CIR STE 100
DOTHAN AL
36301-3023
US

IV. Provider business mailing address

797 STRICKLAND RD
HEADLAND AL
36345-8440
US

V. Phone/Fax

Practice location:
  • Phone: 334-794-1148
  • Fax:
Mailing address:
  • Phone: 334-618-6565
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAG02230064
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: