Healthcare Provider Details

I. General information

NPI: 1841240223
Provider Name (Legal Business Name): MARY ELLEN HUCKABEE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 03/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295B S JACKSON ST
GROVE HILL AL
36451-3231
US

IV. Provider business mailing address

PO BOX 935
GROVE HILL AL
36451-0935
US

V. Phone/Fax

Practice location:
  • Phone: 251-275-3173
  • Fax: 251-275-4281
Mailing address:
  • Phone: 251-275-3173
  • Fax: 251-275-4281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1038498
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: