Healthcare Provider Details

I. General information

NPI: 1780924167
Provider Name (Legal Business Name): SUSAN ANNETTE STAPP CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2013
Last Update Date: 05/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 BROOKLYN RD
HOLLY POND AL
35083-6478
US

IV. Provider business mailing address

111 BROOKLYN RD
HOLLY POND AL
35083-6478
US

V. Phone/Fax

Practice location:
  • Phone: 256-451-1250
  • Fax:
Mailing address:
  • Phone: 256-451-1250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-102990
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: