Healthcare Provider Details

I. General information

NPI: 1235822370
Provider Name (Legal Business Name): EMILY SELF CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2023
Last Update Date: 06/02/2023
Certification Date: 06/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 SIVLEY RD SW
HUNTSVILLE AL
35801-4421
US

IV. Provider business mailing address

PO BOX 040005
HUNTSVILLE AL
35804-4005
US

V. Phone/Fax

Practice location:
  • Phone: 256-265-2372
  • Fax: 256-533-3379
Mailing address:
  • Phone: 256-533-3388
  • Fax: 256-801-6727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-150955
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: