Healthcare Provider Details

I. General information

NPI: 1710445838
Provider Name (Legal Business Name): MIALI PRAYTOR JENNINGS CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2019
Last Update Date: 06/29/2023
Certification Date: 11/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2708 HIGHWAY 78 E
JASPER AL
35501-3430
US

IV. Provider business mailing address

2708 HIGHWAY 78 E
JASPER AL
35501-3430
US

V. Phone/Fax

Practice location:
  • Phone: 205-387-2253
  • Fax:
Mailing address:
  • Phone: 205-387-2253
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1-153373
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number1-153373
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number1-153373
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: