Healthcare Provider Details

I. General information

NPI: 1972047637
Provider Name (Legal Business Name): REBECCA A. NICHOLS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: REBECCA A. FIELDS

II. Dates (important events)

Enumeration Date: 12/14/2016
Last Update Date: 05/05/2021
Certification Date: 05/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 PINE ST
MONTGOMERY AL
36106-1109
US

IV. Provider business mailing address

PO BOX 235019
MONTGOMERY AL
36123-5019
US

V. Phone/Fax

Practice location:
  • Phone: 334-279-1450
  • Fax: 334-395-4115
Mailing address:
  • Phone: 334-279-1450
  • Fax: 334-395-4115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-135519
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: