Healthcare Provider Details

I. General information

NPI: 1679495733
Provider Name (Legal Business Name): NICOLE BISHOP DEROUEN CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2026
Last Update Date: 07/29/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 GREEN ST
GREENSBORO AL
36744-2316
US

IV. Provider business mailing address

199 TAYLOR RD
MOUNDVILLE AL
35474-0138
US

V. Phone/Fax

Practice location:
  • Phone: 334-624-4442
  • Fax:
Mailing address:
  • Phone: 205-292-4786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF06260368
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: