Healthcare Provider Details

I. General information

NPI: 1104362177
Provider Name (Legal Business Name): PHILLIP TYLER STANLEY C.R.N.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2017
Last Update Date: 01/13/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1118 ROSS CLARK CIR
DOTHAN AL
36301-3001
US

IV. Provider business mailing address

1600 KEATING RD
DOTHAN AL
36303-2702
US

V. Phone/Fax

Practice location:
  • Phone: 334-793-8111
  • Fax:
Mailing address:
  • Phone: 334-701-8240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-126879
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: