Healthcare Provider Details

I. General information

NPI: 1265812424
Provider Name (Legal Business Name): BRENDA FAYE GAVIN APRN FNP-C AG-ACNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2015
Last Update Date: 10/02/2020
Certification Date: 10/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MEMORIAL HOSPITAL DR STE 1A
MOBILE AL
36608-1128
US

IV. Provider business mailing address

PO BOX 7987
MOBILE AL
36670-0987
US

V. Phone/Fax

Practice location:
  • Phone: 251-343-6848
  • Fax: 251-343-5708
Mailing address:
  • Phone: 251-633-0573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-087281
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number1-087281
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberR900157
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: