Healthcare Provider Details

I. General information

NPI: 1992253082
Provider Name (Legal Business Name): RICHARD LEE WALDEN CRNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2016
Last Update Date: 11/21/2023
Certification Date: 11/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7125 UNIVERSITY CT
MONTGOMERY AL
36117-8016
US

IV. Provider business mailing address

7125 UNIVERSITY CT
MONTGOMERY AL
36117-8016
US

V. Phone/Fax

Practice location:
  • Phone: 334-239-2622
  • Fax: 334-625-7602
Mailing address:
  • Phone: 334-239-2622
  • Fax: 334-625-7602

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number905672
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number3-001136
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberR895162
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: