Healthcare Provider Details

I. General information

NPI: 1700122553
Provider Name (Legal Business Name): AVA MICHELLE DIRICKSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: AVA SPURLOCK DIRICKSON RN

II. Dates (important events)

Enumeration Date: 12/26/2012
Last Update Date: 12/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 COLISEUM BLVD
MONTGOMERY AL
36109-2707
US

IV. Provider business mailing address

101 COLISEUM BOULEVARD
MONTGOMERY AL
36109
US

V. Phone/Fax

Practice location:
  • Phone: 334-279-7830
  • Fax:
Mailing address:
  • Phone: 334-279-7830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number1-080766
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: