Healthcare Provider Details

I. General information

NPI: 1639492358
Provider Name (Legal Business Name): DENECE CLAYBORNE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2010
Last Update Date: 02/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 ANDREWS AVE.
FORT RUCKER AL
36362-2334
US

IV. Provider business mailing address

301 ANDREWS AVE.
FORT RUCKER AL
36362-2334
US

V. Phone/Fax

Practice location:
  • Phone: 334-255-9915
  • Fax:
Mailing address:
  • Phone: 334-255-9915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number0001165547
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number1-128885
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: