Healthcare Provider Details

I. General information

NPI: 1619711322
Provider Name (Legal Business Name): ELLEN COLLEY THRASH CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2024
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 MITYLENE PARK LN
MONTGOMERY AL
36117-7302
US

IV. Provider business mailing address

185 MITYLENE PARK LN
MONTGOMERY AL
36117-7302
US

V. Phone/Fax

Practice location:
  • Phone: 334-387-0948
  • Fax: 334-387-0955
Mailing address:
  • Phone: 334-387-0948
  • Fax: 334-387-0955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1-169953
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: