Healthcare Provider Details

I. General information

NPI: 1104242395
Provider Name (Legal Business Name): ANGELA KUYKENDALL CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2014
Last Update Date: 02/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 HIGHWAY 78 W
JASPER AL
35501-7505
US

IV. Provider business mailing address

PO BOX 708
JASPER AL
35502-0708
US

V. Phone/Fax

Practice location:
  • Phone: 205-387-2253
  • Fax:
Mailing address:
  • Phone: 205-387-2253
  • Fax: 205-387-2405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-077703
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: