Healthcare Provider Details

I. General information

NPI: 1588378095
Provider Name (Legal Business Name): NICOLE WADDLE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2023
Last Update Date: 06/07/2024
Certification Date: 06/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7480 HALCYON POINTE DR STE 300
MONTGOMERY AL
36117-8111
US

IV. Provider business mailing address

1212 KINGSTON GREEN DR
PRATTVILLE AL
36067-1728
US

V. Phone/Fax

Practice location:
  • Phone: 334-218-4339
  • Fax:
Mailing address:
  • Phone: 334-315-7015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1-164871
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number1-164871
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: