Healthcare Provider Details

I. General information

NPI: 1871706978
Provider Name (Legal Business Name): WILMA DIANE BALIEM CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2007
Last Update Date: 06/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 SPRINGHILL AVENUE
MOBILE AL
36640-0430
US

IV. Provider business mailing address

PO BOX 40430
MOBILE AL
36640-0430
US

V. Phone/Fax

Practice location:
  • Phone: 251-665-8000
  • Fax: 251-665-8010
Mailing address:
  • Phone: 251-665-8000
  • Fax: 251-665-8010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1-046774
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: