Healthcare Provider Details

I. General information

NPI: 1457461790
Provider Name (Legal Business Name): CLAYTON DALE COCKRELL II CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 04/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2131 MILITARY ST S
HAMILTON AL
35570
US

IV. Provider business mailing address

2131 MILITARY ST S
HAMILTON AL
35570-6651
US

V. Phone/Fax

Practice location:
  • Phone: 205-921-5556
  • Fax: 205-921-5595
Mailing address:
  • Phone: 205-921-5556
  • Fax: 205-921-5595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1-099596
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: