Healthcare Provider Details

I. General information

NPI: 1487634267
Provider Name (Legal Business Name): LARRY KEVIN CREEL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 MARENGO ST
FLORENCE AL
35630-6033
US

IV. Provider business mailing address

105 HEATHROW CV
FLORENCE AL
35633-1638
US

V. Phone/Fax

Practice location:
  • Phone: 256-768-8624
  • Fax:
Mailing address:
  • Phone: 256-740-0266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-079476
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: