Healthcare Provider Details

I. General information

NPI: 1134362817
Provider Name (Legal Business Name): NOLA JEAN ERNEST M.D., PH.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2009
Last Update Date: 06/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

526 BOLL WEEVIL CIR ENTERPRISE PEDIATRIC CLINIC
ENTERPRISE AL
36330-4012
US

IV. Provider business mailing address

126 CLINIC DR DOTHAN PEDIATRIC CLINIC
DOTHAN AL
36303-1980
US

V. Phone/Fax

Practice location:
  • Phone: 334-308-1166
  • Fax: 334-308-1019
Mailing address:
  • Phone: 334-793-1881
  • Fax: 334-712-1815

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number31586
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier184547
Identifier TypeMEDICAID
Identifier StateAL
Identifier Issuer
# 2
Identifier016903000
Identifier TypeMEDICAID
Identifier StateFL
Identifier IssuerFlorida Medicaid Provider ID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: