Healthcare Provider Details

I. General information

NPI: 1043940687
Provider Name (Legal Business Name): CLARISSA JORDAN ANNAN CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2022
Last Update Date: 06/15/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

156 E 15TH AVE
GULF SHORES AL
36542-3516
US

IV. Provider business mailing address

1239 LAVENDER LN
FOLEY AL
36535-9565
US

V. Phone/Fax

Practice location:
  • Phone: 251-948-4290
  • Fax: 251-948-7682
Mailing address:
  • Phone: 251-747-0980
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-164543
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: