Healthcare Provider Details

I. General information

NPI: 1720754096
Provider Name (Legal Business Name): ROBERT MCCULLOCH WILLETT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2021
Last Update Date: 04/03/2023
Certification Date: 04/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 GORDON SMITH DR
MOBILE AL
36617-2319
US

IV. Provider business mailing address

2400 GORDON SMITH DR
MOBILE AL
36617-2319
US

V. Phone/Fax

Practice location:
  • Phone: 251-305-4660
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1-166146
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: