Healthcare Provider Details

I. General information

NPI: 1740190826
Provider Name (Legal Business Name): KELLY NICOLE CRISWELL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2026
Last Update Date: 09/10/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15445 AL-24
MOULTON AL
35650
US

IV. Provider business mailing address

156 N POPLAR ST
FLORENCE AL
35630-4855
US

V. Phone/Fax

Practice location:
  • Phone: 256-974-1128
  • Fax:
Mailing address:
  • Phone: 731-694-8633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number24830
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: