Healthcare Provider Details

I. General information

NPI: 1780970665
Provider Name (Legal Business Name): HIBOOMBE M HAAMANKULI CRNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2011
Last Update Date: 06/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

185 MITYLENE PARK LANE
MONTGOMERY AL
36117
US

IV. Provider business mailing address

185 MITYLENE PARK LANE
MONTGOMERY AL
36117
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 Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number1-111413
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: