Healthcare Provider Details

I. General information

NPI: 1265085633
Provider Name (Legal Business Name): MARANDA JARAN FAIN CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2019
Last Update Date: 03/15/2022
Certification Date: 03/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7461 EAST DRIVE SUITE 102
MONTGOMERY AL
36117
US

IV. Provider business mailing address

9095 HELENA DR
PIKE ROAD AL
36064-2477
US

V. Phone/Fax

Practice location:
  • Phone: 334-244-3281
  • Fax: 334-244-3396
Mailing address:
  • Phone: 334-300-2591
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1-131127
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: