Healthcare Provider Details

I. General information

NPI: 1871137844
Provider Name (Legal Business Name): SUSAN SMITH CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2019
Last Update Date: 11/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6321 PICCADILLY SQUARE DR STE A
MOBILE AL
36609-5305
US

IV. Provider business mailing address

7030 CLOVERLEAF LANDING RD
BAY MINETTE AL
36507-5733
US

V. Phone/Fax

Practice location:
  • Phone: 251-342-8900
  • Fax:
Mailing address:
  • Phone: 251-721-2933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number1-136348
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: