Healthcare Provider Details

I. General information

NPI: 1962564203
Provider Name (Legal Business Name): REBECCA DIANNA WORSHAM CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4258 HIGHWAY 231 STE 5
LACEYS SPRING AL
35754-6444
US

IV. Provider business mailing address

4258 HIGHWAY 231 STE 5
LACEYS SPRING AL
35754-6444
US

V. Phone/Fax

Practice location:
  • Phone: 256-498-5770
  • Fax: 256-498-5799
Mailing address:
  • Phone: 256-498-5770
  • Fax: 256-498-5799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-057030
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: