Healthcare Provider Details

I. General information

NPI: 1720754674
Provider Name (Legal Business Name): JENNIFER ANN ROSE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2021
Last Update Date: 05/16/2024
Certification Date: 05/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2410 AVALON AVE
MUSCLE SHOALS AL
35661-3283
US

IV. Provider business mailing address

2410 AVALON AVE
MUSCLE SHOALS AL
35661-3283
US

V. Phone/Fax

Practice location:
  • Phone: 256-386-0808
  • Fax: 256-389-8904
Mailing address:
  • Phone: 256-386-0808
  • Fax: 256-389-8904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number1-155978
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number1-155978
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: